Heartland Global Health Consortium

Has Primary Health Care become a Global Orphan

2008-09-29T06:32:00.000-07:00

Has PHC Become a Global Orphan?, Anthony Seddoh, Pambazuka News 398, 9/25/08
With progress towards quality primary health care still slow some thirty years after Alma-Ata, Anthony Seddoh writes that an effective global alliance of global and country actors needs to set positive and realistic paths to implement the declaration’s intentions. In light of the continuing absence of a conceptual framework for addressing longstanding debates and organisational issues, the author considers whether primary health care represents a global orphan in need of fresh guardianship.
Thirty years after the 1978 Declaration of Alma-Ata, it seems the world is still at odds on how best to implement the principles of primary health care. The slow progress in improving health outcomes for all raises questions about the effectiveness of current ways of doing business. A concerted global alliance of global and country actors needs to set positive and realistic paths to implement the intentions of Alma-Ata.
Sixty years ago, the World Health Organization (WHO) stated in its constitution that health is ‘a state of physical, mental and social wellbeing, not only the absence of disease or infirmity.’ Thirty years later, the Alma-Ata declaration on Primary Health Care (PHC) declared among other things that ‘health is a fundamental right’ and created a thirteen-point outline to ensure this right. This outline captured concepts of essential care, universally accessibility and affordability for individuals and families within communities, who would be able to participate fully in a spirit of self-determination.
It located PHC as an integral part of a country’s health system involving all related sectors and aspects of national and community development.
The WHO constitution’s definition of health and the Alma-Ata declaration together prompt a diametrical but complementary state to be addressed concurrently in the promotion of good health. The first deals with the clinical determinants of health, pushing for the absence of disease in individuals. The second addresses the determinants of health that predispose or prevent individuals from attaining a state of mental, physical and social wellbeing as a fundamental right. These include appropriate governance, the absence of war, economic and infrastructure development, adequate infrastructure and aid policies. A unique moment occurred in 1978 to bring these complementary understandings together.
Even before the ink could dry on the Alma-Ata declarations it had however already generated polarised antagonism. From a capitalist standpoint, it was a ridiculous proposition, both too costly and defying economic reasoning, and too socialist in its excessive emphasis on state-managed intervention. The conservative duo of J.A. Walsh and K.S. Warren launched the Selective PHC debate, arguing that it would probably more be efficient to save children and limit population growth, while the two main PHC proponents, WHO and UNICEF, soon drifted apart, with UNICEF promoting a selective package of low cost interventions. With resource flows following Selective PHC, Primary Health Care translated in most countries into a basic collection of services to be delivered at district and community levels based on a select number of interventions with some outreach services, with an accompanying watered-down district health package.
Why nobody asked at the time whether there was any moral significance to be attached to a person’s life or pointed out that choices based on state preferences for total health gain can be justified over financial resource allocation efficiency is difficult to comprehend. Aside from efficiency-based arguments being ridiculous propositions founded on utility-based preferences or embodying unattractive equity assumptions, the economic bargain in a healthy population should at least have also appealed to responsible international choice.
Much has since been achieved from the advance in technology in dealing with specific clinical determinants of specific diseases. It could be argued that a saturation point has been reached, where increases in financial and human investments in existing technologies are yielding less than proportional gains. Despite this the selective interventions approach continues to define health and health services delivery. It was given a new lease on life by the World Bank through its 1993 World Development Report, entitled ‘Investing in Health’. This report, which scarcely acknowledged PHC, commoditised and de-linked health from development and moved the world closer to an interventionist approach to health; intervening at a selective point in the epidemiology of a disease or health system.
This approach has since had wide global appeal. Currently there are over thirty WHO resolutions on AIDS, TB or Malaria alone; more than all other subjects. The Millennium Development Goals (MDGs) have further entrenched this disease-specific approach to resource mobilisation. There are over 80 major global health initiatives linked to the health MDGs, providing over US$100 million annually. The Italian Global Health Watch reported in 2008 that the Global Fund has allocated approximately US$3.5 billion to countries for interventions on AIDS, TB and Malaria, mainly in Africa. Together, these initiatives have thrown billions of dollars at addressing diseases and improving clinical health conditions and made up a significant part of health sector budgets.
PHC is hardly mentioned in these initiatives, seldom highlighted by member states outside of anniversaries of the initiatives or occasional references to district health system strengthening. For various reasons the world assumed an emergency mode to address what are considered new and urgent public health issues. Single disease interventions that lend themselves to easily recognisable financial accountability, quantitative monitoring and evaluation held greater appeal for funders, especially when twinned with arguments of weak domestic governance and public policy failures and capacity limitations.
While these initiatives on clinical determinants hummed with measurable outcomes on specific diseases, the nexus of poverty and ill health was exacerbated. On the back of a growing trend in urban slum development, decline in state services, market failures in privatised economies, growing food insecurity and massive deprivation of rights to health care, inequalities in health have deepened to a significantly greater level over the past 30 years.
Hence while a lot has been done to deal with disease in individuals, the unique opportunity provided by the Alma-Ata Declaration to also address the determinants of health have largely been lost. Thirty years later we see the costs of this omission in levels of poverty which belie the levels of knowledge and technological advance achieved globally.
As we approach another anniversary for PHC expectations are high. People expect that their physical and mental health will be promoted in a safe social, economic and political environment. They expect to have quality health systems that provide preventive services, and which diagnose, treat and manage disease injury and reduce the severity and repeated occurrence of disease. They do not expect to see wide social and economic disparities in these basic entitlements. In Africa, the region furthest from delivery on these expectations, the Ouagadougou declaration on Primary Health Care issued on April 30 2008 called for a renewal of the Principles of Primary Health Care and its implementation in developing countries and by the international community.
Such declarations are encouraging, yet their implementation calls for resolution of longstanding debates of the past 30 years. These debates are not academic. In choices made over policy measures, relative allocation of institutional, social and financial resources and complementary systems for dealing with the social determinants of health (mostly dealt with by actions outside the health sector), they present social and economic inequalities that arise due to the burden of disease (mostly dealt with within the health sector). There are no clear answers for how a conceptual framework of Primary Health Care in 2008 will address this.
And while there is a massive coalition of global initiatives dealing with diseases, there is no clear coalition of global institutions supporting or funding the determinants of health, the second factor in the PHC equation. At a global level, the Bretton Woods institutions and OECD initiatives for debt relief and poverty reduction have in some African countries led to short-lived increases in spending on health and education, with no global initiatives so far adequately addressing the determinants of health.
This leaves PHC as an orphan with no global guardian. The WHO’s attempt to foster PHC is inadequate given the pluralistic global environment. The state of poverty and the winds of change in international health resource priorities will make rational choices among the various dimensions impossible and predispose countries to the dictate of new interventions and their implementation. While debates over the conceptual understanding of PHC will not end in 2008, this year could at least mark the turning point for a new institutional response, one that builds a global alliance to generate the momentum and support for countries to implement PHC and that provide policy learning based on practice from the bottom up, reminiscent of another basis for the Alma-Ata declaration.
A WHO or UN resolution creating such a global alliance would be a befitting PHC birthday gift for the millions of people seeking more than another conference. It will squarely put implementation right at the doorstep of a recognisable entity that can mobilise the needed funds and offer effective support to individual countries.

Washington Post article

2008-09-19T12:52:00.000-07:00

Check out the website to read about, "For a Global Generation, Public Health is a hot field"

http://www.washingtonpost.com/wp-dyn/content/article/2008/09/18/AR2008091804145.html?referrer=emailarticle

Conference Subcommittee report

2008-06-27T07:35:00.000-07:00

Heartland Global Health Consortium
Conference Subcommittee

The Central College house is reserved for consortium use from January 3- January 10, 2009. The original instruction to the committee was to plan a six- or seven-day conference, but several members of the subcommittee have suggested that a shorter conference might be more attractive to potential participants. Two proposed schedules are provided at the conclusion of this document, and the subcommittee invites comment from other consortium participants.

The Central College property in Merida includes a large house (a former governor’s mansion) with 9 bedrooms and 5 bathrooms. The bedrooms are very large and can accommodate up to 4 people each. There are several gathering spaces, both inside and outside. A palapa (classroom that is outdoors, but covered) seats at least 30 people. Several large and small patios and decks are also well suited for small group discussions.

Central College is willing to provide accommodation, including lodging, all meals, field trip transportation costs, etc. for a fee of $500 per person or less, depending on which schedule we choose. Some consortium members may choose to lodge at a nearby hotel (we will provide costs and other details in the near future). Discussions with Valerie Grimsley, Central College program director in Merida suggest that the optimal number of participants for this conference is no more than 30.

Objectives for the conference are:

Speakers/Sessions Days: To educate ourselves about the most pressing issues and approaches that are of current and future concern to scholars and professionals working in the field of global public health.
Field Trips: To explore how public health issues of pressing concern are addressed in both rural and urban settings in Merida and surrounding communities. To consider ways in which transnational influences on these communities either exacerbate or ameliorate public health problems.
Planning Day: To consider ways in which the consortium can best serve to strengthen faculty and student interest and learning with respect to global public health at member institutions. Focus on concrete plans for collaboration according to the division of labor represented by our present committee structure.

See next page for proposed schedules

Schedule Option 1
(4 days plus travel)

Day 1: Travel (reception or other activity in evening, depending on flight availability)
Day 2: Field trip to rural village, followed by siesta, discussion, and reflection
Day 3: Presentations from local experts and public health officials
Day 4: Field trip to urban area, followed by siesta, discussion, and reflection
Day 5: Consortium strategy session
Day 6: Travel

Schedule Option 2
(6 days plus travel)

Day 1: Travel
Day 2: Orientation to Merida (market, walking tour, etc.)
Day 3: Presentations from local experts and public health officials
Day 4: Visit to urban community, reflection and discussion
Day 5: Visit to rural community, reflection and discussion
Day 6: Presentations from local experts
Day 7: Excursion to Uxmal
Day 8: Travel

Education Subcommittee report

2008-06-12T10:42:00.000-07:00

Heartland Global Health Consortium

Education Subcommittee Report March 8, 2008

Chair: Ellie DuPre?

General Purpose:
To develop multidisciplinary educational programs that will allow students and faculty in the consortium to participate in understanding and promoting public awareness of global health issues.

Objectives:
(1) Develop a certificate program in Global Public Health
· Credit hours
· Core courses
· Elective courses

(2) Develop a Masters Degree program in Global Public Health
· Credits hours
· Core courses
· Electives courses

(3) Determine and establish matriculation protocol between all participating consortium members

(4) Determine the best means to implement the programs.
· Class availability:
– evenings
– summer
– weekends
– online

Program assumptions:
· Courses should be multidisciplinary
· Emphasis should be on significant international health issues including their (both local and global) social, political, economic and, cultural dimensions as appropriate to ensure better understanding of the availability of resources for public health in developing countries.
· Experiential learning and study abroad should be a component of the core

Discussions concerning the make up of the core and possible elective courses have begun.

Funding & Development subcommittee report

2008-05-30T11:25:00.000-07:00

Funding and Development Committee
Report
March 7, 2008

Members: Raylene Rospond, Chair; Mary Mincer Hansen, Brian Zylstra, Hsain Ilahiane

General Purpose: Developing relationships between schools and finding funding sources for the work of the consortium.

Objectives

Information sharing
Leveraging joint resources to sustain consortium
Attracting new Resources
Advocate for Global Health education
Facilitate networking between students and Faculty t
Promote Public Awareness in Global
Share Study abroad opportunities (mix student levels
Promote Alumni Involvement
Develop Iowa Global Health Database

Activities to date

1) The Blogger user Hsain Ilahiane has invited you to contribute to the blog: Heartland Global Health Consortium.

To contribute to this blog, visit:
http://www.blogger.com/i.g?inviteID=5520353644698935498&blogID=2736134306248244043

You'll need to sign in with a Google Account to confirm the invitation and start posting to this blog. If you don't have a Google Account yet, we'll show you how to get one in minutes.

2) Initial investigation into funding opportunities

Laurie Garrett paper 3

2008-05-16T07:00:00.000-07:00

Home Subscribe Current Issue

The Next Pandemic?
By Laurie Garrett
From Foreign Affairs , July/August 2005

Summary: Since it first emerged in 1997, avian influenza has become deadlier and more resilient. It has infected 109 people and killed 59 of them. If the virus becomes capable of human-to-human transmission and retains its extraordinary potency, humanity could face a pandemic unlike any ever witnessed.
Laurie Garrett is Senior Fellow for Global Health at the Council on Foreign Relations and is the author of The Coming Plague and Betrayal of Trust.

PROBABLE CAUSE
Scientists have long forecast the appearance of an influenza virus capable of infecting 40 percent of the world's human population and killing unimaginable numbers. Recently, a new strain, H5N1 avian influenza, has shown all the earmarks of becoming that disease. Until now, it has largely been confined to certain bird species, but that may be changing.
The havoc such a disease could wreak is commonly compared to the devastation of the 1918-19 Spanish flu, which killed 50 million people in 18 months. But avian flu is far more dangerous. It kills 100 percent of the domesticated chickens it infects, and among humans the disease is also lethal: as of May 1, about 109 people were known to have contracted it, and it killed 54 percent (although this statistic does not include any milder cases that may have gone unreported). Since it first appeared in southern China in 1997, the virus has mutated, becoming heartier and deadlier and killing a wider range of species. According to the March 2005 National Academy of Science's Institute of Medicine flu report, the "current ongoing epidemic of H5N1 avian influenza in Asia is unprecedented in its scale, in its spread, and in the economic losses it has caused."
In short, doom may loom. But note the "may." If the relentlessly evolving virus becomes capable of human-to-human transmission, develops a power of contagion typical of human influenzas, and maintains its extraordinary virulence, humanity could well face a pandemic unlike any ever witnessed. Or nothing at all could happen. Scientists cannot predict with certainty what this H5N1 influenza will do. Evolution does not function on a knowable timetable, and influenza is one of the sloppiest, most mutation-prone pathogens in nature's storehouse.
Such absolute uncertainty, coupled with the profound potential danger, is disturbing for those whose job it is to ensure the health of their community, their nation, and broader humanity. According to the Centers for Disease Control and Prevention (CDC), in a normal flu season about 200,000 Americans are hospitalized, 38,000 of whom die from the disease, with an overall mortality rate of .008 percent for those infected. Most of those deaths occur among people older than 65; on average, 98 of every 100,000 seniors with the flu die. Influenza costs the U.S. economy about $12 billion annually in direct medical costs and loss of productivity.
Yet this level of damage hardly approaches the catastrophe that the United States would face in a severe flu pandemic. The CDC predicts that a "medium-level epidemic" could kill up to 207,000 Americans, hospitalize 734,000, and sicken about a third of the U.S. population. Direct medical costs would top $166 billion, not including the costs of vaccination. An H5N1 avian influenza that is transmittable from human to human could be even more devastating: assuming a mortality rate of 20 percent and 80 million illnesses, the United States could be looking at 16 million deaths and unimaginable economic costs. This extreme outcome is a worst-case scenario; it assumes failure to produce an effective vaccine rapidly enough to make a difference and a virus that remains impervious to some antiflu drugs. But the 207,000 reckoning is clearly a conservative guess.
The entire world would experience similar levels of viral carnage, and those areas ravaged by HIV and home to millions of immunocompromised individuals might witness even greater death tolls. In response, some countries might impose useless but highly disruptive quarantines or close borders and airports, perhaps for months. Such closures would disrupt trade, travel, and productivity. No doubt the world's stock markets would teeter and perhaps fall precipitously. Aside from economics, the disease would likely directly affect global security, reducing troop strength and capacity for all armed forces, UN peacekeeping operations, and police worldwide.
In a world where most of the wealth is concentrated in less than a dozen nations representing a distinct minority of the total population, the capacity to respond to global threats is, to put it politely, severely imbalanced. The majority of the world's governments not only lack sufficient funds to respond to a superflu; they also have no health infrastructure to handle the burdens of disease, social disruption, and panic. The international community would look to the United States, Canada, Japan, and Europe for answers, vaccines, cures, cash, and hope. How these wealthy governments responded, and how radically the death rates differed along worldwide fault lines of poverty, would resonate for years thereafter.

WHAT ONCE WAS LOST
Nearly half of all deaths in the United States in 1918 were flu related. Some 675,000 Americans -- about 0.6 percent of the population of 105 million and the equivalent of 2 million American deaths today -- perished from the Spanish flu. The average life expectancy for Americans born in 1918 was just 37 years, down from 55 in 1917. Although doctors then lacked the technology to test people's blood for flu infections, scientists reckon that the Spanish flu had a mortality rate of just less than one percent of those who took ill in the United States. It would have been much worse had there not been milder flu epidemics in the 1850s and in 1889, caused by similar but less virulent viruses, which made most elderly Americans immune to the 1918-19 strain. The highest death tolls were among young adults, ages 20-35.
The Spanish flu got its name because Spain suffered from an early and acute outbreak, but it did not originate there. Its actual origin remains uncertain. The first strain was mild enough to prompt most World War I military forces to dismiss it as a pesky ailment. When the second strain hit North America in the summer of 1918, however, the virus caused a surge of deaths. First hit was Camp Funston, an army base in Kansas, where young soldiers were preparing for deployment to Europe. The virus then spread swiftly to other camps and on troop ships crossing the Atlantic, killing 43,000 U.S. military personnel in about three months. Despite the entreaties of the military's surgeons general, President Woodrow Wilson ordered continued shipments of troops aboard crowded naval transports, which soldiers came to call "death ships." By late September 1918, so overwhelmed was the War Department by influenza that the military could not assist in controlling civic disorder at home, including riots caused by epidemic hysteria. Worse, so many doctors, scientists, and lab technicians had been drafted into military service that civilian operations were hamstrung.
Under these conditions, influenza swept from the most populous U.S. cities to extraordinarily remote rural areas. Explorers discovered empty Inuit villages in what are now Alaska and the Yukon Territory, their entire populations having succumbed to the flu. Many deaths were never included in the pandemic's official death toll -- such as the majority of victims in Africa, Latin America, Indonesia, the Pacific Islands, and Russia (then still in the throes of revolution). What is known about the toll in these regions is staggering. For example, influenza killed 5 percent of the population of Ghana in only two months, and nearly 20 percent of the people of Western Samoa died. The official estimate of 40-50 million total deaths is believed to be a conservative extrapolation of European and American records. In fact, many historians and biologists believe that nearly a third of all humans suffered from influenza in 1918-19 -- and that of these, 100 million died.
In the last years of the nineteenth century and the early years of the twentieth, a series of important scientific discoveries spawned a revolution in biology and medicine and led pioneers such as Hermann Biggs, a New York City doctor, to create entire legal and health systems based on the identification and control of germs. By 1917, the United States and much of Europe had become enthralled by the hygiene movement. Impressive new public health infrastructures had been built in many cities, tens of thousands of tuberculosis victims were isolated in sanatoriums, the incidences of child-killing diseases such as diphtheria and typhoid fever had plummeted, and cholera epidemics had become rare events in the industrialized world. There was great optimism that modern science held the key to perfect health.
Influenza's arrival shattered the hope; scientists still had virtually no understanding of viruses generally, and of influenza in particular. The hygienic precautions and quarantines that had proved so effective in holding back the tide of bacterial diseases in the United States proved useless, even harmful, in the face of the Spanish flu. As the epidemic spread, top physicians and scientists claimed its cause was everything from tiny plants to old dusty books to something called "cosmic influence." It was not until 1933 that a British research team finally isolated and identified the influenza virus.
Most strains of the flu do not kill people directly; rather, death is caused by bacteria, which surge into the embattled lungs of the victim. But the Spanish flu that circulated in 1918-19 was a direct killer. Victims suffered from acute cyanosis, a blue discoloration of the skin and mucous membranes. They vomited and coughed up blood, which also poured uncontrollably from their noses and, in the case of women, from their genitals. The highest death toll occurred among pregnant women: as many as 71 percent of those infected died. If the woman survived, the fetus invariably did not. Many young people suffered from encephalitis, as the virus chewed away at their brains and spinal cords. And millions experienced acute respiratory distress syndrome, an immunological condition in which disease-fighting cells so overwhelm the lungs in their battle against the invaders that the lung cells themselves become collateral damage, and the victims suffocate. Had antibiotics existed, they may not have been much help.

OOPS
In January 1976, 18-year-old Private David Lewis staggered his way through a forced march during basic training in a brutal New Jersey winter. By the time his unit returned to base at Fort Dix, Lewis was dying. He collapsed and did not respond to his sergeant's attempts at mouth-to-mouth resuscitation.
In subsequent weeks, U.S. Army and CDC scientists discovered that the virus that had killed Lewis was swine flu. Although no other soldiers at Fort Dix died, health officials panicked. F. David Matthews, then secretary of health, education, and welfare, promptly declared, "There is evidence there will be a major flu epidemic this coming fall. The indication is that we will see a return of the 1918 flu virus that is the most virulent form of flu. In 1918, a half million people died [in the United States]. The projections are that this virus will kill one million Americans in 1976."
At the time, it was widely believed that influenza appeared in cycles, with especially lethal forms surfacing at relatively predictable intervals. Since 1918-19, the United States had suffered through influenza pandemics in 1957-58 and 1968-69; the first caused 70,000 deaths and the second 34,000. In 1976, scientists believed the world was overdue for a more lethal cycle, and the apparent emergence of swine flu at Fort Dix seemed to signal that another wave had come. The leaders of the CDC and the Department of Health, Education, and Welfare (HEW) warned the White House that there was a reasonably high probability that a catastrophic flu pandemic was about to hit. But opinion was hardly unanimous, and many European and Australian health authorities scoffed at the Americans' concern. Unsure of how to gauge the threat, President Gerald Ford summoned the polio-fighting heroes Jonas Salk and Albert Sabin to Washington and found the long-time adversaries in remarkable accord: a flu pandemic might truly be on the way.
On March 24, 1976, Ford went on national television. "I have just concluded a meeting on a subject of vast importance to all Americans," he announced. "I have been advised that there is a very real possibility that unless we take effective counteractions, there could be an epidemic of this dangerous disease next fall and winter here in the United States. ... I am asking Congress to appropriate $135 million, prior to the April recess, for the production of sufficient vaccine to inoculate every man, woman, and child in the United States."
Vaccine producers immediately complained that they could not manufacture sufficient doses of vaccine in such haste without special liability protection. Congress responded, passing a law in April that made the government responsible for the companies' liability. When the campaign to vaccinate the U.S. population started four months later, there were almost immediate claims of side effects, including the neurologically debilitating Guillain Barré Syndrome. Most of the lawsuits -- with claims totaling $3.2 billion -- were settled or dismissed, but the U.S. government still ended up paying claimants around $90 million.
Swine flu, however, never appeared. The head of the CDC was asked to resign, and Congress never again considered assuming the liability of pharmaceutical companies during a potential epidemic. The experience weakened U.S. credibility in public health and helped undermine the stature of President Ford. Subsequently, an official assessment of what went wrong was performed for HEW by Dr. Harvey Fineberg, a Harvard professor who is currently president of the Institute of Medicine.
Fineberg concluded:"In this case the consequences of being wrong about an epidemic were so devastating in people's minds that it wasn't possible to focus properly on the issue of likelihood. Nobody could really estimate likelihood then, or now. The challenge in such circumstances is to be able to distinguish things so you can rationally talk about it. In 1976, some policymakers were simply overwhelmed by the consequences of being wrong. And at a higher level [in the White House] the two -- likelihood and consequence -- got meshed."
Fineberg's warnings are well worth remembering today, as scientists nervously consider H5N1 avian influenza in Asia. The consequences of a form of this virus that is transmittable from human to human, particularly if it retains its unprecedented virulence, would be disastrous. But what is the likelihood that such a virus will appear?

DEVOLUTION
Understanding the risks requires understanding the nature of H5N1 avian flu specifically and influenza in general. Influenza originates with aquatic birds and is normally carried by migratory ducks, geese, and herons, usually without harm to them. As the birds migrate, they can pass the viruses on to domesticated birds -- chickens, for example -- via feces or during competitions over food, territory, and water. Throughout history, this connection between birds and the flu has spawned epidemics in Asia, especially southern China. Aquatic flu viruses are more likely to pass into domestic animals -- and then into humans -- in China than anywhere else in the world. Dense concentrations of humans and livestock have left little of China's original migratory route for birds intact. Birds that annually travel from Indonesia to Siberia and back are forced to land and search for sustenance in farms, city parks, and industrial sites. For centuries, Chinese farmers have raised chickens, ducks, and pigs together, in miniscule pens surrounding their homes, greatly increasing the chance of contamination: influenza can spread from migrating to domestic birds and then to swine, mutating and eventually infecting human beings.
Ominously, as China's GDP grows, so do the expensive appetites of the country's 1.3 billion people, more of whom can afford to eat chicken regularly. Today, China annually raises about 13 billion chickens, 60 percent of them on small farms. Chicken farming is quickly morphing into a major industry, with some commercial poultry plants rivaling those in Arkansas and Georgia in scale -- but lagging behind in hygienic standards. These factors favor rapid influenza evolution. By the close of the twentieth century, at least two new types of human-to-human flu spread around the world every year.
Influenza viruses contain eight genes, composed of RNA and packaged loosely in protective proteins. Like most RNA viruses, influenza reproduces sloppily: its genes readily fall apart, and it can absorb different genetic material and get mixed up in a process called reassortment. When influenza successfully infects a new species -- say, pigs -- it can reassort, and may switch from being an avian virus to a mammalian one. When that occurs, a human epidemic can result. The transmission cycles and the constant evolution are key to influenza's continued survival, for were it to remain identical year after year, most animals would develop immunity, and the flu would die out. This changing form explains why influenza is a seasonal disease. Vaccines made one year are generally useless the following.
Among the eight influenza genes there are two, dubbed H and N, that provide the code for proteins recognized by the human immune system. Scientists have numbered the many types of H and N proteins and use this system to classify a virus. A different viral combination of H and N proteins will trigger a different human immune response. For example, if a strain of H2N3 influenza circulates one year, followed by a different variety of H2N3 the next year, most people will be at least partially immune to the second strain. But if an H2N3 season is followed by an outbreak of H3N5 influenza, few people will have any immunity to the second virus, and the epidemic could be enormous. But a widespread epidemic need not be a severe or particularly deadly one: a virus' virulence depends on genes other than the two that control the H and N proteins.
Scientists first started saving flu virus samples in the early twentieth century. Since that time, an H5N1 influenza has never spread among human beings. According to the World Health Organization (WHO), "No virus of the H5 subtype has probably ever circulated among humans, and certainly not within the lifetime of today's world population. Population vulnerability to an H5N1-like pandemic virus would be universal." As for virulence, within about 48 hours of infection, H5N1 avian influenza kills 100 percent of infected chickens -- although the virulence of a potential human-to-human transmissible H5N1 is impossible to predict.
A team of Chinese scientists has been tracking the H5N1 virus since it first emerged in Hong Kong in 1997, killing 6 people and sickening 18 others. The strain came out of southern China's Guangdong Province, where it apparently was carried by ducks, and hit Hong Kong's chicken population hard. After authorities there killed 1.5 million chickens -- almost every single one in Hong Kong -- the outbreak seemed to stop. But the virus had not disappeared; rather, it had retreated to China's Guangdong, Hunan, and Yunnan provinces, spreading once again to aquatic birds.
From 1998 to 2001 the virus went through multiple reassortments and moved back to domestic birds, spreading almost unnoticed in Chinese chicken flocks. It continued to evolve at high speed: 17 more reassortments occurred, and in January 2003 the "Z" virus emerged, a mutant powerhouse that had become tougher, capable of withstanding a wider range of environmental challenges. The Z virus spread to Vietnam and Thailand, where it evolved further, becoming resistant to one of the two classes of antiflu drugs, known as amantadines, or M2-inhibitors.
In early 2004, it became supervirulent and capable of killing a broad range of species, including rodents and humans. That permutation of the virus was dubbed "Z+." In the first three weeks of January 2004, Z+ killed 11 million chickens in Vietnam and Thailand. By April 2004, 120 million chickens in Asia had died of flu or been exterminated to slow the influenza brushfire. The avian epidemic stopped for a while, but in July another 1 million chickens died from the disease. The Z+ virus was causing massive internal bleeding in the birds. By the beginning of 2005, with chickens dying and customers shying away from what remained, the Asian poultry industry had lost nearly $15 billion.
By April 2005, the H5N1 virus had also moved to pigs. Scientists isolated the disease from swine in a part of Indonesia where pigs are raised underneath elevated wood-slatted platforms that house chickens. Less rigorous investigations had previously indicated that pigs in China and Vietnam may also have been infected by H5N1 influenza. The discovery in Indonesia provided disturbing evidence that the virus was infecting mammals, although it was not yet known how widely the swine disease had spread or how lethal it was for the animals.

HARD TO KILL
Over the course of this brief but rapid evolution, the H5N1 virus developed in ways unprecedented in influenza research. It is not only incredibly deadly but also incredibly difficult to contain. The virus apparently now has the ability to survive in chicken feces and the meat of dead animals, despite the lack of blood flow and living cells; raw chicken meat fed to tigers in Thailand zoos resulted in the deaths of 147 out of a total of 418. The virus has also found ways to vastly increase the range of species it can infect and kill. Most strains of influenza are not lethal in lab mice, but Z+ is lethal in 100 percent of them. It even kills the very types of wild migratory birds that normally host influenza strains harmlessly. Yet domestic ducks, for unknown reasons, carry the virus without a problem, which may explain where Z+ hides between outbreaks among chickens.
Traditional Asian methods of buying, slaughtering, and cooking meat make it hard to track the spread of an influenza virus -- and tracking it is critical to preventing the disease from spreading. In Asia, consumers prefer to buy live chickens and other live animals at the market, slaughtering them in home kitchens. Asians thus have a high level of exposure to potentially disease-carrying animals, both in their homes and as they pass through the markets that line the streets of densely packed urban centers. For someone trying to trace a disease, Asia is a nightmare: with people daily exposed to live chickens in so many different environments, how can a sleuth tell whether an ailing flu victim was infected by a chicken, a duck, a migratory heron -- or another human being?
Although most of the 109 known human H5N1 infections have been ascribed to some type of contact with chickens, mysteries abound, and many cases remain unsolved. "The virus is no longer causing large and highly conspicuous outbreaks on commercial farms," a 2005 WHO summary of the human Z+ cases states. "Nor have poultry workers or cullers turned out to be an important risk group that could be targeted for protection. Instead, the virus has become stealthier: human cases are now occurring with no discernible exposure to H5N1 through contact with diseased or dead birds."
If proximity to infected animals is the key, why have there been no deaths among chicken handlers, poultry workers, or live-chicken dealers? The majority of the infected have been young adults and children. And there has been one documented case of human-to-human transmission of the Z+ strain of the H5N1 virus -- in late 2004, in Thailand. Several more such cases are suspected but cannot be confirmed. According to the WHO, there is "no scientific explanation for the unusual disease pattern."
Assessing and understanding H5N1's virulence in humans has also proved elusive. When it first appeared in Hong Kong in 1997, the virus killed 35 percent of those it was known to have infected. (Less severe cases may not have been reported.) The Z strain of the disease, which emerged in early 2003, killed 68 percent of those known to have been infected. In H5N1 cases since December 2004, however, the mortality has been 36 percent. How can the fluctuation over time be explained? One disturbing possibility is that H5N1 has begun adapting to its human hosts, becoming less deadly but easier to spread. In the spring of 2005, in fact, H5N1 infected 17 people throughout Vietnam, resulting in only three deaths. Leading flu experts argue that this sort of phenomenon has in the past been a prelude to human influenza epidemics.
The medical histories of those who have died from H5N1 influenza are disturbingly similar to accounts of sufferers of the Spanish flu in 1918-19. Otherwise healthy people are completely overcome by the virus, developing all of the classic flu symptoms: coughing, headache, muscle pain, nausea, dizziness, diarrhea, high fever, depression, and loss of appetite. But these are just some of the effects. Victims also suffer from pneumonia, encephalitis, meningitis, acute respiratory distress, and internal bleeding and hemorrhaging. An autopsy of a child who died of the disease in Thailand last year revealed that the youth's lungs had been torn apart in the all-out war between disease-fighting cells and the virus.

BAD MEDICINE
According to test-tube studies, Z+ ought to be vulnerable to the antiflu drug oseltamivir, which the Roche pharmaceuticals company markets in the United States under the brand name Tamiflu. Yet Tamiflu was given to many of those who ultimately succumbed to the virus; it is believed that medical complications induced by the virus, including acute respiratory distress syndrome, may have prevented the drug from helping. It is also difficult to tell whether the drug contributed to the survival of those who took it and lived, although higher doses and more prolonged treatment may have a greater impact in fighting the disease. A team of Thai clinicians recently concluded that "the optimal treatment for case-patients with suspected H5 infection is not known." Lacking any better options, the WHO has recommended that countries stockpile Tamiflu to the best of their ability. The U.S. Department of Health and Human Services is doing so, but supplies of the drug are limited and it is hard to manufacture.
What about developing a Z+ vaccine? Unfortunately, there is only more gloom in the forecast. The total number of companies willing to produce influenza vaccines has plummeted in recent years, from more than two dozen in 1980 to just a handful in 2004. There are many reasons for the decline in vaccine producers. A spate of corporate mergers in the 1990s, for example, reduced the number of major international pharmaceutical companies. The financial risk of investing in vaccines is also a key factor. In 2003, the entire market for all vaccines -- from polio to measles to hepatitis to influenza -- amounted to just $5.4 billion. Although that sum may seem considerable, it is less than two percent of the global pharmaceutical market of $337.3 billion. Unlike chemical compounds, vaccines and most other biological products are difficult to make and can easily become contaminated. There is also a large and litigious antivaccine constituency -- some people believe that vaccines cause harmful side effects such as Alzheimer's disease and autism -- adding considerable liability costs to manufacturers' bottom lines.
The production of influenza vaccines holds particular drawbacks for companies. Flu vaccines must be made rapidly, increasing the risk of contamination or other errors. Because of the seasonal nature of the flu, a new batch of influenza vaccines must be produced each year. Should sales in a given year prove disappointing, flu vaccines cannot be stockpiled for sale in a subsequent season because by then the viruses will have evolved. In addition, the manufacturing process of flu vaccines is uniquely complex: pharmaceutical companies must grow viral samples on live chicken eggs, which must be reared under rigorous hygienic conditions. Research is under way on reverse genetics and cellular-level production techniques that might prove cheaper, faster, and less contamination-prone than using eggs, but for the foreseeable future manufacturers are stuck with the current laborious method. After cultivation, samples of the viruses must be harvested, the H and N characteristics must be shown to produce antibodies in test animals and human volunteers, and tests must prove that the vaccine is not contaminated. Only then can mass production commence.
The H5N1 strain of avian flu poses an additional problem: the virus is 100 percent lethal to chickens -- and that includes chicken eggs. It took researchers five years of hard work to devise a way to grow the 1997 version of the H5N1 virus on eggs without killing them; although there have been technological improvements since then, there is no guarantee that an emerging pandemic strain could be cultivated fast enough.
In the current system, all influenza vaccines must be quickly made following a WHO meeting of flu experts held every February. At that gathering, scientists scrutinize all available information on the flu strains known to be circulating in the world. They then try to predict which strains are most likely to spread across every continent in the next six to nine months. (This year the WHO committee chose three human flu strains, of types H3N2 and H1N1, to be the basis of the next vaccine.) Samples of the chosen strains are delivered to pharmaceutical companies around the world for vaccine production, and the vaccines are hopefully available to the public by September or October -- a few months after influenza typically strikes Asia, in the early summer. Europe and the Americas are usually hit shortly after, in September. Because viruses constantly change themselves, the process cannot be executed earlier in the year.
Although new technology may allow an increase in production capacity, manufacturers have never made more than 300 million doses of flu vaccine in a single year. The slow pace of production means that in the event of an H5N1 flu pandemic millions of people would likely be infected well before vaccines could be distributed.

GLOBAL REACH
The scarcity of flu vaccine, although a serious problem, is actually of little relevance to most of the world. Even if pharmaceutical companies managed to produce enough effective vaccine in time to save some privileged lives in Europe, North America, Japan, and a few other wealthy nations, more than six billion people in developing countries would go unvaccinated. Stockpiles of Tamiflu and other anti-influenza drugs would also do nothing for those six billion, at least 30 percent of whom -- and possibly half -- would likely get infected in such a pandemic.
Resources are so scarce that both wealthy and poor countries would be foolish to count on the generosity of their neighbors during a global outbreak. Were the United States to miraculously overcome its vaccine production problems and produce ample supplies for U.S. citizens, Washington would probably deny the vaccine to neighbors such as Mexico, since governments tend to reserve vaccine supplies for their own citizens during emergencies. Were the United States to falter, it would probably not be able to rely on Canadian or European generosity, as it did just last year. When the United Kingdom suspended the license for the Chiron Corporation's U.K. production facility for flu vaccine due to contamination problems, Canada and Germany bailed the United States out, supplying additional doses until the French company Sanofi Pasteur could manufacture more. Even with this assistance, however, the United States' vaccine needs were not fully met until February 2005 -- the tail end of the flu season.
In the event of a deadly influenza pandemic, it is doubtful that any of the world's wealthy nations would be able to meet the needs of their own citizenry -- much less those of other countries. Domestic vaccine purchasing and distribution schemes currently assume that only the very young, the elderly, and the immunocompromised are at serious risk of dying from the flu. That assumption would have led health leaders in 1918 to vaccinate all of the wrong people. Then, the young and the old fared relatively well, while those aged 20 to 35 -- today typically the lowest priority for vaccination -- suffered the most deaths from the Spanish flu. And so far, H5N1 influenza looks like it could have a similar effect: its human victims have all fallen into age groups that would not be on national vaccine priority lists, and because H5N1 has never circulated among humans before, it is highly conceivable that all ages could be susceptible. Every year, trusting that the flu will kill only the usual risk groups, the United States plans for 185 million vaccine doses. If that guess were wrong -- if all Americans were at risk -- the nation would need at least 300 million doses. That is what the entire world typically produces each year.
There would thus be a global scramble for vaccine. Some governments might well block foreign access to supplies produced on their soil and bar vaccine export. Since little vaccine is actually made in the United States, this could prove a problem for Americans in particular. Facing such limited supplies, the U.S., European, and Japanese governments might give priority to vaccinating heads of state around the world in hopes of limiting social chaos. But who among the elite would be eligible? Would their families be included? How could such a global triage be executed justly?
A similar calculus might be necessary for countries engaged in significant military operations. Troop movements would certainly help spread the disease, just as World War I aided the growth of the 1918-19 Spanish flu. Back then, the flu wreaked havoc on combatant nations. In the summer of 1918, influenza killed far more soldiers than did bombs, bullets, or mustard gas. By October, some 46 percent of the French army was off the field of battle -- ailing, dying, or caring for flu victims. Influenza death tolls among the various military forces generally ranged from 5 to 10 percent, but some segments fared even worse: historian John Barry has reported that 22 percent of the Indian members of the British military died.
In the event of a modern pandemic, the U.S. Department of Defense, with the lessons of World War I in mind, would undoubtedly insist that U.S. troops in Iraq and Afghanistan be given top access to vaccines and antiflu drugs. About 170,000 U.S. forces are currently stationed in Iraq and Afghanistan, while 200,000 more are permanently based elsewhere overseas. All of them would potentially be in danger: in late March, for example, North Korea conceded it was suffering a large-scale H7N1 outbreak -- taking place within miles of some 41,000 U.S. military forces. It is impossible to predict how such a pandemic influenza would affect U.S. operations in Iraq, Afghanistan, Colombia, or any other place.
Armed forces throughout the world would face similar issues. Most would no doubt pressure their governments for preferential access to vaccine and medications. In addition, more than a quarter of some African armies and police forces are HIV positive, perhaps making them especially vulnerable to influenza's lethal impact. Social instability resulting from troop and police losses there would likely be particularly acute.
Such a devastating disease would clearly have profound implications for international relations and the global economy. With death tolls rising, vaccines and drugs in short supply, and the potential for the virus to spread further, governments would feel obliged to take drastic measures that could inhibit travel, limit worldwide trade, and alienate their neighbors. In fact, the Z+ virus has already demonstrated its disruptive potential on a limited scale. In July 2004, for example, when the Z+ strain reemerged in Vietnam after a three-month hiatus, officials in the northern province of Bac Giang charged that Chinese smugglers were selling old and sickly birds in Vietnamese markets -- where more than ten tons of chickens are smuggled daily. Chinese authorities in charge of policing their side of the porous border, more than 1,000 kilometers long, countered that it was impossible to inspect all the shipments. Such conflicts are now limited to the movement of livestock, but if a pandemic develops they could well escalate to a ban on trade and human movement.
Although there is little evidence that isolation measures have ever slowed the spread of influenza -- it is just too contagious -- most governments would likely resort to quarantines in a pandemic crisis. Indeed, on April 1, 2005, President George W. Bush issued an executive order authorizing the use of quarantines inside the United States and permitting the isolation of international visitors suspected of carrying influenza. If one country implements such orders, others will follow suit, bringing legal international travel to a standstill. The SARS (severe acute respiratory syndrome) virus, which was less dangerous than a pandemic flu by several orders of magnitude, virtually shut down Asian travel for three months.
As great as they would be, the economic consequences of travel restrictions, quarantines, and medical care would be well outstripped by productivity losses. In a typical flu season, productivity costs are ten times greater than all other flu-related costs combined. The decline in productivity is usually due directly to worker illness and absenteeism. During a pandemic, productivity losses would be even more disproportionate because entire workplaces -- schools, theaters, and public facilities -- would be shut down to limit human-to-human spread of the virus. Workers' illnesses also would likely be even more severe and last even longer than normal. Frankly, no models of social response to such a pandemic have managed to factor in fully the potential effect on human productivity. It is therefore impossible to reckon accurately the potential global economic impact.

AILING
The potential for a pandemic comes at a time when the world's public health systems are severely taxed and have long been in decline. This is true in both rich and poor countries.
The Bush administration recognized this weakness following the anthrax scare of 2001, which underscored the poor ability of federal and local health agencies to respond to bioterrorism or epidemic threats. Since that year, Congress has approved $3.7 billion to strengthen the nation's public health infrastructure. In 2003, the White House also took several steps to improve the nation's capacity to respond to a flu pandemic: it increased funding for the CDC's flu program by 242 percent, to $41.6 million in 2004; gave the National Institutes of Health an additional 320 percent in funds for flu-related research and development, for a total of $65.9 million; increased spending on the Food and Drug Administration's licensing capacity for flu vaccines and drugs by 173 percent, to $2.6 million; and spent an additional $80 million to create new stockpiles of Tamiflu and other anti-influenza drugs. On August 4, 2004, the Department of Health and Human Services also issued its pandemic flu plan, detailing further steps that would be taken by federal and state agencies in the event of a pandemic. Several other countries have released similar plans of action.
But despite all this, a recent event underscored the United States' tremendous vulnerability. In October 2004, the American College of Pathologists mailed a collection of mystery microbes prepared by a private lab to almost 5,000 labs in 18 countries for them to test as part their recertification. The mailing should have been routine procedure; instead, in March 2005 a Canadian lab discovered that the test kits included a sample of H2N2 flu -- a strain that had killed four million people worldwide in 1957. H2N2 has not been in circulation since 1968, meaning that hundreds of millions of people lack immunity to it. Had any of the samples leaked or been exposed to the environment, the results could have been devastating. On learning of the error, the WHO called for the immediate destruction of all the test kits. Miraculously, none of the virus managed to escape any of the labs.
But the snafu raises serious questions: If billions have been spent to improve laboratory capabilities since 2001, why did nobody notice the H2N2 flu until about six months after the kits had been shipped? Why did a private company possess samples of the virulent flu? Why was the sample included in the kits? In the aftermath of the September 11, 2001, attacks and the anthrax scare, many countries reclassified 1957-58 and 1968-69 influenza strains as Level 3 pathogens, requiring extreme care in their handling, distribution, and storage -- why did the United States still consider H2N2 to be a mere Level 2 pathogen, a type frequently mailed and studied? Finally, around the world, what other labs -- public and private -- currently possess samples of such lethal influenza viruses? The official CDC answer to these questions is, "We don't know."
Even with all of these gaps, probably the greatest weakness that each nation must individually address is the inability of their hospitals to cope with a sudden surge of new patients. Medical cost cutting has resulted in a tremendous reduction in the numbers of staffed hospital beds in the wealthy world, especially in the United States. Even during a normal flu season, hospitals located in popular retirement areas have great difficulty meeting the demand. In a pandemic, it is doubtful that any nation would have adequate medical facilities and personnel to meet the extra need.
National policymakers would be wise to plan now for worst-case scenarios involving quarantines, weakened armed services, and dwindling hospital space and vaccine supplies. But at the end of the day, effectively combating influenza will require multilateral and global mechanisms. Chief among them, of course, is the WHO, which since 1947 has maintained a worldwide network that conducts influenza surveillance. The WHO system oversees laboratories all over the world, chases (and sometimes refutes) rumors of pandemics, pushes for government transparency regarding human and avian flu cases, and acts as an arbiter in negotiations over vaccine production, trade embargoes, and border disputes. Its companion UN agency, the Food and Agriculture Organization (FAO), working closely with the World Organization for Animal Health, monitors flu outbreaks in animal populations and advises governments on culling flocks and herds, cross-border animal trade, animal husbandry and slaughter, and livestock quarantine and vaccination. All of these organizations have published lengthy guidelines on how to respond to a pandemic flu, lists of answers to commonly asked questions, and descriptions of their research priorities -- most of which have been posted on their Web sites.
The efforts of these agencies should be bolstered, both with expertise and dollars. The WHO, for example, has an annual core budget of just $400 million, a tiny increment of which is spent on influenza- and epidemic-response programs. (In comparison, the annual budget of New York City's health department exceeds $1.2 billion.) An unpublished internal study estimates that the agency would require at least another $600 million for its flu program were a pandemic to erupt. It is in every government's interest to give the WHO and the FAO the authority to act as impartial voices during a pandemic, able (theoretically) to assess objectively the epidemic's progress and rapidly evaluate research claims. The WHO in particular must have adequate funding and personnel to serve as an accurate clearinghouse of information about the disease, thereby preventing the spread of false rumors and global panic. No nation can erect a fortress against influenza -- not even the world's wealthiest country.
Few members of the U.S. Congress or its legislative counterparts around the world were alive when the great Spanish flu swept the planet. There may be some who lost parents, aunts, or uncles to the 1918-19 pandemic, and perhaps even more have heard the horror stories that were passed down. But politics breeds shortsightedness, and for decades the threat of an influenza pandemic has been easily forgotten, and therefore ignored at budget time. Politicians and health leaders made many serious errors in 1918-19; some historians say that President Wilson sent 43,000 soldiers to their deaths by forcing them aboard crowded ships to join a war he had already won. But in those days, human beings had no understanding of their influenza foe.
In 1971, the great American public health leader Alexander Langmuir likened flu forecasting to trying to predict the weather, arguing that "as with hurricanes, pandemics can be identified and their probable course projected so that warnings can be issued. Epidemics, however, are more variable [than hurricanes], and the best that can be done is to estimate probabilities."
Since Langmuir's time a quarter of a century ago, weather forecasting has gained a stunning level of precision. And although scientists cannot tell political leaders when an influenza pandemic will occur, researchers today are able to guide policymakers with information and analysis exponentially richer than that which informed the decisions of President Ford and the 1976 Congress. Whether or not this particular H5N1 influenza mutates into a human-to-human pandemic form, the scientific evidence points to the potential that such an event will take place, perhaps soon. Those responsible for foreign policy and national security, the world over, cannot afford to ignore the warning.

Home Subscribe Current Issue

www.foreignaffairs.org is copyright 2002--2006 by the Council on Foreign Relations. All rights reserved.

Laurie Garrett paper 2

2008-05-16T06:58:00.000-07:00

Home Subscribe Current Issue

The Lessons of HIV/AIDS
By Laurie Garrett
From Foreign Affairs , July/August 2005

Summary: To get a sense of the broader damage a new pandemic might do, it helps to consider the one the world is currently enduring: HIV/AIDS. Because this deadly scourge moves slowly, many of its social, political, and economic effects have yet to be understood. But the impact is hard to overstate. And it is growing.
Laurie Garrett is Senior Fellow for Global Health at the Council on Foreign Relations. This essay partly results from meetings convened by the council in collaboration with the Joint UN Programme on HIV/AIDS.

SECURITY AT STAKE
If the deadly bird flu discussed in the previous three essays were ever to sweep across the world, the impact on national security would be obvious everywhere. Nations rich and poor would quickly recognize the vulnerabilities of their citizens, economies, public health systems, and armed forces.
But what about the security implications of an existing pandemic, HIV/AIDS, the full impact of which is taking years to be felt? When the disease first struck, few leaders of the hardest-hit countries in sub-Saharan Africa acknowledged the links between HIV/AIDS, social stability, and national security. It took many of them two decades to face facts, and by then HIV/AIDS had spread through their populations and killed large numbers. Nor was such myopia limited to Africa; it was prevalent in developed countries as well. The resulting delays have caused millions of deaths around the world.
Were the Asian bird flu to start infecting humans, the death toll would rise even more quickly. Preparation is therefore critical. Unfortunately, the example of the HIV/AIDS pandemic is not reassuring. Adequate resources for combating the disease have yet to be marshaled, even though the potential for it to cause destabilization has now been recognized at the international level. In 2000, the UN Security Council issued Resolution 1308, warning that the HIV/AIDS pandemic, if unchecked, could threaten world stability and security. Five years after its passage, the resolution will be formally reviewed this July.
AIDS has killed at least 26 million people, orphaning more than 12 million children, and today the virus afflicts 40 million people directly. Although the illness was first officially recognized in the United States in 1981, it has raged in the Great Lakes region of Africa since the 1970s. And yet policymakers still lack sufficient data, computer modeling, and empirical analyses of the disease for effective guidance on prevention and treatment. As a result, the pandemic's impact on economic activity, agricultural practices, childhood development, and the credibility of political leaders is still poorly understood. Too little is known about its effects on businesses in hard-hit countries, which lose upward of three percent of their labor forces to the virus every year. Even less is known about infection rates in most police and armed forces.
Nevertheless, three crucial points have become clear. First, HIV/AIDS is the most complex disease humanity has ever faced and presents it with unprecedented challenges of research and analysis. Second, new threats to stability and security may emerge as the pandemic escalates. Third, a well-conceived campaign to curtail the virus, particularly through development of an effective HIV vaccine, could short-circuit the attendant security concerns. Such a campaign would be achievable. But it has yet to be undertaken.

DEATH IN SLOW MOTION
Unlike the massive pandemics of the past, such as the Black Death or the influenza outbreak of 1918-19, HIV/AIDS inflicts death very slowly. For three decades, the current pandemic has created waves of infection, followed years later by waves of acute disease, and years after that by waves of death and family disruption. In the prior two megaplagues, the periods between infection, illness, and death and family disruption were days to weeks. Entire societies experienced the shock simultaneously, grieved in unison, and witnessed the impact on the society and state as one.
In the case of HIV/AIDS, however, the intervals between these waves have lasted up to 14 years, and the waves themselves have been staggered, with the progression of infection and illness varying from person to person and region to region. Successive high-amplitude waves have swept over sub-Saharan Africa for up to four human generations. On the other hand, low-amplitude waves have gone almost unnoticed for ten years or more in India, Indonesia, Russia, Southeast Asia, and Ukraine. Only now are these areas experiencing large-scale infection. Illness, death, and the mass creation of orphans are still ahead.
Even within Africa, the timing of HIV/AIDS and its impact have varied. The Great Lakes region has been suffering for 35 years now, long enough that every facet of society there has been reshaped. On the other hand, Botswana, Malawi, Swaziland, and most of western Africa are now in a third generation of low-amplitude waves. South Africa, Namibia, and Angola have yet to experience the full death tolls of their first, rapidly rising wave of infection.
Around the world, affected societies have begun to adapt to the changes wrought by AIDS to varying degrees: extended families have started absorbing orphans, communities have begun altering farming practices, and governments have started increasing their health spending. Thailand, for example, has successfully adopted effective containment measures (such as massive condom distribution and public education) that have brought the epidemic under a remarkable degree of control, both in the country's military and its civilian population. Uganda, conversely, may be backsliding after what seemed like early progress against the disease. Ugandan scientists warn that the apparent downward trend in HIV/AIDS there may merely be a hiatus in the epidemic, caused not by an effective AIDS-control campaign but by the wholesale death of the infected adult population; April 2005 data show that adult infection rates are indeed climbing. If these analysts are correct, Uganda could experience yet another round of infection, disease, and death when today's youth become sexually active adults.
The long shock waves caused by AIDS, moreover, are washing over many countries that are simultaneously being swamped by other diseases -- malaria, tuberculosis, childhood dysentery, gonorrhea, antibiotic-resistant bacterial infections, and newly emerging infections such as severe acute respiratory syndrome (SARS) and the Marburg virus. Many of these countries also suffer from other problems that impede economic development and cause social disruption, such as military conflict and social unrest. It is therefore extremely difficult to predict how HIV/AIDS will affect these states and their societies, economies, cultures, and politics. The full impact may not be known for a generation, and the results will vary around the planet. The Joint UN Programme on HIV/AIDS and the Shell Corporation have attempted to model the pandemic's future, and their forecasts are gloomy. And even these predictions depend on government actions that may not be taken.
Politicians are usually shortsighted, and those making HIV/AIDS policy have proved to be no exception. To date, no HIV/AIDS policy enacted by any government or by the UN addresses more than one HIV/AIDS wave's worth of activity, and most epidemic policies have only been implemented in reaction to specific instances of public outcry. Few political leaders and officials recognize that current anti-HIV/AIDS drugs are not curative and, to fend off death, must be taken daily for the rest of a patient's life. The World Health Organization, in a program funded by rich nations, intends by year's end to equip a modest three million people in poor countries with antiretroviral drugs. But to be effective, the program must last for many years rather than be a one-time expense. If wealthy donors cut off their assistance, few poor countries will be able to pick up the treatment costs on their own. A massive wave of death would ensue, as the rich world turned off the life support system of all three million people.

MILITARY MATTERS
When assessing the effects of HIV/AIDS on most military and police forces, two factors stand out. First, infection among uniformed personnel has risen sharply. Second, the rate of infection in most countries' forces is at least as high as it is among their civilians. In Russia, the HIV/AIDS rate among potential 18-year-old draftees has shot up 25-fold since 1999. The annual new infection rate for HIV in Russia's military forces has also risen sharply, climbing from about 0.1 cases per 100,000 soldiers in 1995 to nearly 40 per 100,000 in 2003. In both 2002 and 2003, about 5,000 conscripts -- or about a third of all young men drafted -- were rejected for military service for health reasons that included, chiefly, HIV/AIDS, tuberculosis, drug addiction, and "psychological problems."
Murray Feshbach, a noted demographer at the Woodrow Wilson International Center for Scholars, has written that Russia will find it increasingly difficult to staff its army as illness claims more of its youth and its overall population shrinks. Feshbach sees similar trends in the armed forces of Ukraine, the Baltic states, and possibly Belarus and Moldova as well. The HIV/AIDS and tuberculosis epidemics in these countries are spiraling out of control, probably growing faster than anywhere else in the world.
This is not to say that HIV infection among police and armed forces elsewhere is not also a grave problem. Troop strength in Malawi, for example, has already reportedly fallen to 50 percent of the minimum capacity needed to guarantee state security. In 2004, the Zimbabwe Ministry of Defense admitted that the military's HIV infection rate was about 3 percent higher than that of Zimbabwe's civilian society, which was then just above 26 percent. In Mozambique, police recruits cannot be trained fast enough to replace those dying of AIDS. High HIV infection rates have impeded South Africa's attempts to transform its previously all-white military command into one that more closely mirrors South African society. In Ethiopia, a 2004 test of police officers' wives found that nearly a third of them were HIV positive. Nothing is publicly known about the HIV rates within the world's two largest military forces: China's 2.5 million-strong People's Liberation Army, and India's 1.33 million-member defense forces. Nor is much known about the levels of infection in the rest of Asia's military and police forces. In May, however, India's minister of defense stated that AIDS was the fifth-leading cause of death for his nation's armed forces.
Dead recruits and infantry troops tend to be easy to replace. A general or top technical officer, however, often represents decades of training and acquired experience. Around the world, many militaries are quietly putting their infected commanders on antiretroviral medicines, in hopes of buying time to train their replacements. U.S. military experience reveals the wisdom of this move, as HIV/AIDS-related death rates among infected U.S. armed forces plummeted from 40 percent during the period from 1985 to 2001 to just 1.4 percent since 2001, thanks largely to such treatment. Brazil's experience, however, offers a stark counterpoint. Brazil, like the United States, has also used antiretroviral drugs to treat the estimated one percent of its uniformed personnel who are HIV positive. But the Brazilian officers and enlisted men treated have grown steadily more resistant to the drugs, with some 86 percent of affected personnel now reporting resistance to at least one of the powerful protease-inhibitor drugs used to hold the virus at bay.
There are four essential conclusions that can be drawn from the available information about HIV infection among military and police forces. First, in hard-hit parts of the world, these individuals, who are the protectors of stability and security, are increasingly falling victim to AIDS -- as much or more so than the general adult population. As death claims ever more citizens, it will also claim more troops, posing serious problems for law and order a decade from now.
Second, in some areas with high infection rates, especially in the former Soviet Union, militaries and police are finding it hard to identify healthy recruits to replace the ranks of their aging and HIV-infected forces. Third, while many uniformed services are supplying antiretroviral drugs to their command officers in the hope of prolonging their lives, providing these drugs solely to the upper echelons may eventually undermine morale among the rank and file, even leading to mutinies. Such special treatment may also undermine the moral authority of the police and the military among the general population. And even the life-prolonging wonders of antiretroviral drugs may be short-lived, due to the emergence of drug-resistant strains of HIV.
The HIV/AIDS pandemic is also having a major impact on UN peacekeepers. All military personnel stationed with UN operations are by regulation encouraged to undergo voluntary HIV screening. In addition, the UN's roughly 47,000 peacekeepers all receive training about the risks of AIDS, other sexually transmitted diseases, and appropriate behavior with civilian personnel. They also all get a plastic "HIV/AIDS Awareness Card for Peacekeeping Operations" and five or six condoms a week during foreign deployment. Most of the 65,000 peacekeepers perform their work with noble courage and free of HIV risk.
Nevertheless, the UN has recently been rocked by sex-related scandals among peacekeepers in the Democratic Republic of the Congo and elsewhere, and several studies show that troops stationed away from their home countries are at significant risk for acquiring HIV. A Nigerian military survey, for example, has found that the infection rate among soldiers who are based near their wives and homes mirrors that of society at large -- about five percent. But rates among those deployed for peacekeeping operations in Sierra Leone, Liberia, and Côte d'Ivoire are up to three times higher. Nigeria has witnessed a stark increase in noncombat mortality in its military ranks over the last five years, with 43 percent of that surge directly ascribed to HIV.
One counterintuitive effect of warfare, as the recent histories of Angola, Cambodia, Ethiopia, Namibia, Nigeria, South Africa, and Zimbabwe show, is that it can actually reduce the risk of HIV infection. During wartime, civilians either hunker down in their homes or flee war-torn regions and become refugees. Trade grinds to a halt, borders are locked tight, and social mobility is minimized.
Consider Angola, for example. For 27 years, it was wracked by a civil war that left the now-peaceful nation in shambles. War, however, largely kept HIV outside Angola, since most forms of trade and travel, both within the country and across its borders, were essentially shut down for three decades. Since the end of the conflict in 2002, Angola's borders have reopened. Peace has brought greater trade -- but also an increased HIV infection rate.
One critical and horrifying exception to the general dampening effect of warfare on the rate of HIV infection occurs when rape is used as a weapon. A recent study of women who were raped during the 1994 Rwanda genocide shows that today nearly 80 percent of them are HIV positive. Similarly, a survey of pregnant women in parts of northern Uganda where the rebel paramilitary group the Lord's Resistance Army has committed atrocities, including rapes, for two decades finds that female infection rates are double those in the rest of Uganda. About half of the rape victims who survived the Sierra Leone civil war are also infected.

ON THE TRAIL OF THE DISEASE
DNA fingerprinting is proving to be a vital tool in pinpointing how various HIV strains and clades (subgroups) move around the world. Using DNA testing, researchers have proved that the rapidly growing HIV/AIDS epidemic in the former Soviet Union comes from a new strain and is being spread by an infection method -- narcotics injection -- that minimizes the mutation of the virus as it passes from one victim to another. As this evidence suggests, the HIV/AIDS epidemic in the former Soviet Union may well pose security threats to the region, but it is a domestic phenomenon and cannot be ascribed to outside forces.
In contrast, molecular evidence paints a very different picture for Asia, where several different clades (and unique recombinations of those clades) are now circulating in the area that spans from eastern India to southern Vietnam. Several research teams have proved that these various HIV clades can be tracked along four major routes, all originating in Myanmar. One type can be traced to a route that runs from the forest regions of eastern Myanmar into Yunnan, China. A second strain has followed the same route, and then continued up to Xinjiang, China. A third runs through Laos, into northern Vietnam, and then into Guangxi, China. And a fourth travels from western Myanmar to Manipur, India.
Surveys conducted at significant risk inside Myanmar -- a weak state governed by a corrupt junta; riven by civil war; beset by rival gangs of drug, gem, and sex-slave smugglers; and one of the world's top opium producers -- show that the various types of HIV are concentrated in key population groups in the country. The highest infection rates are found among prostitutes, who account for about half of all those infected, and among heroin users, who suffer from infection rates as high as 77 percent in the country's north. HIV cases and specific HIV subtypes cluster in poppy-growing regions and then travel along heroin-smuggling routes across Asia. This evidence suggests that Myanmar may be the greatest contributor of new types of HIV in the world. In fact, there has been only one outbreak of HIV in Central Asia that seems to have originated anywhere else.
Africa's epidemic is much more difficult to track genetically than Asia's because it is much older and involves enormously diverse strains of the pathogen. Most perplexing is the situation in Congo, where war has raged for years, engaging military forces from all over the continent and peacekeepers from all over the world. Scientists find the area too dangerous to work in, making it almost impossible to gather samples of the HIV strains there. What evidence is available, however, suggests that Congo has become a mixing pot for HIV, with dozens of unique forms of the virus circulating in the vast nation.
As the case of Congo illustrates, the use of genetics as a form of verification or to track the spread of HIV is currently limited by the way blood samples are collected. Most sampling around the world is performed by scientists seeking to answer questions unrelated to HIV, and genetic studies on those samples are usually conducted by still another group of experts. Funding should be made available to support the targeted collection and analysis of samples. Scientists engaged in such efforts would need protection, such as that currently provided for UN weapons inspectors, as the regions most likely responsible for promulgating and spreading new forms of HIV tend to be among the world's most dangerous.
Funding such efforts would have an enormous benefit: it would help scientists understand the overall evolution of HIV. The virus mutates at a very high rate, and since its appearance in human beings several decades ago, HIV has burst out into many genetic branches. At the moment, no scientist can say where this evolution is headed or what new attributes the virus might one day acquire. Studying the virus' evolution could help answer those questions.

AIDS AND POLITICS
The most obvious political dimension of the security threat caused by HIV/AIDS is the risk that it will claim the lives of national leaders, as parliamentarians, cabinet members, ministers, and the military become infected and die. Until now, such deaths have generally gone unacknowledged: the deceased are listed as victims of tuberculosis, "prolonged illness," or other less stigmatizing problems. To date, the death of not one head of state has officially been designated an AIDS death. Nevertheless, the illness has taken its toll, depriving many nations of seasoned leaders and institutional experience. For example, between 1964 and 1984, Zambia held 14 by-elections to replace incumbents who had died in office. In 1984, the country officially acknowledged its first AIDS case, and between that time and 2003, the number of by-elections soared to 102. Of this total, 29 were due to the death of the incumbent. Each of these special elections represented a loss of political experience and came at enormous monetary expense to the government. The Institute for Democracy in South Africa has published long lists of similar figures for countries all over sub-Saharan Africa.
The ranks of Africa's civil servants are also being thinned by the pandemic, rendering some previously weak bureaucracies only marginally functional. In areas with the highest HIV infection rates, even those government workers who survive often miss work due to the exigencies of caring for relatives or rearing the children of deceased family members. The UN AIDS program has documented the steady erosion of key civil-service sectors in sub-Saharan Africa. Teachers, hospital workers, and financial-sector employees have been the hardest hit.
As serious as these problems are, the most profound challenge to state stability caused by HIV/AIDS will be the death toll among men and women aged 20-50 years, who are workers, parents, leaders, and trained professionals. Already, AIDS is distorting the populations of some countries, where the older, dependent population remains comparatively intact and children and adolescents are coming to radically outnumber adults. Throughout much of sub-Saharan Africa, life expectancy has dropped precipitously.
Nicholas Eberstadt, of the American Enterprise Institute, argues that declining life expectancy constitutes the single most important threat to the security of hard-hit countries, as it will lead to diminishing state capacity. According to the U.S. Census Bureau, 40 nations will have declining life expectancies by 2010, and in 35 of them, HIV/AIDS will be the primary cause (25 of these countries are in sub-Saharan Africa). Eight Caribbean nations and seven former Soviet states will also see their life expectancies drop compared to 1990 levels, and some of the declines will be due to HIV/AIDS. It may not always be possible to tease out the impact of AIDS from the toll inflicted by its frequent companions, such as tuberculosis, malaria, and poverty. But it is noteworthy that the key reversals in life expectancy seen in Africa started between 1985 and 1990, when the first great wave of AIDS deaths swept through the region. In Malawi, by 2000 life expectancy had fallen to the country's 1969 level, essentially reversing 30 years of development investment. Life expectancy in Botswana dropped by 30 years between 1990 and 2002 -- a decline that is unprecedented in known human history.
Most of the countries now hit hardest by HIV/AIDS already had "youth bulges" before the virus arrived, meaning that a disproportionate percentage of their populations were under 29 years of age. HIV/AIDS is now exaggerating these bulges, with the greatest percentage increases appearing in the adolescent population. In 1975, only 17 countries in the world had youth bulges so severe that more than half of their population fell in the 15-29 age bracket. Today, 37 countries belong to that category, nearly all of them in sub-Saharan Africa. Several studies show that countries that had such radically large youth bulges in the period between 1990 and 2000 were three times more likely to suffer civil wars, coups, or armed insurrections.
In general, the presence of three key population problems in a given country indicate a likelihood of instability: a youth bulge, rapidly rising population concentrations in underdeveloped cities, and poor crop or fresh-water production. Fortunately, in many countries, all three of these factors are subsiding, thanks to economic improvements and the strengthening of civil society. But in the poorest parts of the world, they are becoming increasingly pronounced, with dangerous consequences.
That HIV/AIDS is hitting hardest precisely those areas most afflicted by dire poverty may make it impossible to observe direct disease impacts on most local and regional economies. Nevertheless, the pandemic is pouring salt on economic wounds and exacerbating already widening chasms in wealth and food security, and this process will only get worse in the future. The presence of HIV/AIDS also dissuades outside investment, as few companies are interested in building operations in a region where labor productivity and costs are so dramatically affected by disease and death.

RICH VERSUS POOR
Widening gaps in access to anti-HIV drugs are creating glaring differences between the life expectancies of infected Americans and victims in the rest of the world. Resentment is building in both middle-income and poor nations, as the wealthiest nine countries become gerontocracies, while the poorest nations witness the evaporation of previous development gains, rising foreign debts, and increased mortality rates.
In his 2002 State of the Union address, President George W. Bush called for a $15 billion program to combat HIV/AIDS, largely on a bilateral basis, in 14 countries. Known as PEPFAR (the President's Emergency Plan for AIDS Relief), the program eventually added a 15th country (Vietnam) to its list of targets. As of March 2005, PEPFAR had spent only three percent of its funds, providing treatment to 155,000 people worldwide. The program plans to treat 200,000 people by June 2005. PEPFAR has also provided supportive (that is, nonmedical) care to 1.7 million people affected by the epidemic, including 630,000 orphans. As currently conceived, PEPFAR will treat 2 million people by the end of 2008 and provide other types of care to another 10 million. No other nation has mounted an HIV/AIDS campaign of this scale, though many have contributed to the UN's Global Fund to Fight AIDS, Tuberculosis, and Malaria, which sponsors treatment and prevention campaigns worldwide that rival the scale of the U.S. effort.
In 2004, the appropriations bill allocating money for PEPFAR stipulated that a third of the prevention and education funds had to be spent on abstinence-promoting programs, that none of the money could be spent buying sterile syringes or needles for intravenous drug users, and that faith-based organizations should receive special priority in the receipt of care and treatment funds. A more recent White House stipulation has required recipient countries and organizations to denounce prostitution. All of these restrictions have proved enormously controversial, both inside the United States and overseas. Brazil, for example, recently rejected U.S. support on the grounds that it would not be possible to promote safer sexual practices among prostitutes and their clients while morally castigating them. As a result of such strictures, PEPFAR is hardly winning many hearts and minds. Perceptions will likely improve, however, if Congress continues funding the program and U.S.-backed treatment becomes far more available and visible.

AIDS PAST AND FUTURE
Trying to imagine the future shape of the HIV/AIDS pandemic, some two or three waves ahead, is exceedingly difficult. Were the global community now engaged in a highly motivated, multibillion-dollar campaign involving ever more tools (including condoms) in the public health kit, coupled with a Manhattan Project-scale effort to discover and develop an effective HIV vaccine, there might be some cause for optimism. But no such programs exist. If no effective vaccine or cure is found within the next 20 years, areas of the world that are now witnessing explosive epidemics or are in their second or third wave of HIV infection may well find themselves harder hit -- and more deeply transformed -- than Europe was by the Black Death. Many of Africa's characteristics today mirror those of preplague Europe, including an enormous surplus of unskilled labor, a lack of clear property rights for the bulk of the population, domination by tiny elites, widespread warfare waged both by state and mercenary forces, and a transition under way from dispersed agrarian to disastrously urbanized societies. Each of these economic, political, and social characteristics of early fourteenth-century Europe was turned upside down by the Black Death. There is no reason to imagine that Africa's modern plague will have any less of an impact, albeit in slow motion.
The introduction of treatment options for HIV/AIDS could both mitigate and exacerbate the changes. Using antiretroviral therapy to treat key leaders and sectors of society -- including armed forces -- will stretch out the intervals between waves of the pandemic in those select populations. This delay will, in turn, give governments a better chance to cope, both at the national and local levels. But inequitable access to medicine is already creating global tension, as governments in poor countries become angry that they cannot afford to give their people life-sparing drugs that are readily available in wealthy countries. If poor and middle-income countries start using external funds to provide life-extending medicines to their elites, they risk creating the same tensions domestically. On the other hand, the survival of certain states may literally depend on their leaders (including military commanders, top politicians, physicians, teachers, and important bureaucrats) getting access to the medicines.
For donor states the best option is to bite the bullet and spend heavily not only on HIV/AIDS prevention, care, and treatment, but also on development aimed at bringing the poor world into the global economy, so that it may eventually derive sufficient wealth to pay for the great expenses involved with coping with HIV/AIDS.
Given the risks to armed forces, police, and UN peacekeepers, international programs aimed at preventing high-risk sexual activities and drug use, as well as those that provide condoms and sterile needles, should be bolstered and financially supported by wealthy nations.
Viral genetic fingerprinting should be used to trace the spread of HIV and identify key national or transnational forces (such as heroin smuggling) associated with its spread. Global security may require spotting dangerous new evolutionary trends in the virus.
The paucity of reliable data regarding the current effects of pandemics on economic and social issues remains a serious concern. Major scientific institutions in North America, Europe, and Japan should fund and promote such science, conducted in collaboration with researchers from hard-hit regions. Longitudinal cohort studies should be created now to track over the coming decades key population groups, such as children orphaned by AIDS, agricultural workers, soldiers, peacekeepers, migrant workers, and miners.
It bears repeating that were extremely aggressive prevention and vaccine research efforts executed and well funded today, they could render the security concerns of tomorrow moot. Sadly, such funding has not been forthcoming. In 2004, total global spending on HIV vaccine development, public and private, was $680 million, $526 million of which came from the U.S. government and $70 million of which came from private corporations and charities. That amounted to just one percent of total spending on HIV-related programs.
In the aftermath of September 11, 2001, the United States tends to define all national security concerns through the prism of terrorism. That framework is overly limited even for the United States, and an absurdly narrow template to apply to the security of most other countries. The HIV/AIDS pandemic is aggravating a laundry list of underlying tensions in developing, declining, and failed states. As the burden of death due to HIV/AIDS skyrockets around the world over the next five to ten years, the disease may well play a more profound role on the security stage of many nations, and present the wealthy world with a challenge the likes of which it has never experienced. How countries, rich and poor, frame HIV/AIDS within their national security debates today may well determine how well they respond to the massive grief, demographic destruction, and security threats that the pandemic will present tomorrow.

Home Subscribe Current Issue

www.foreignaffairs.org is copyright 2002--2006 by the Council on Foreign Relations. All rights reserved.

Laurie Garrett paper 1

2008-05-16T06:57:00.000-07:00

Missed Opportunities
Governance of Global Infectious Diseases
From International Health, Vol. 27 (1) - Spring 2005
Laurie Garrett is Senior Fellow for Global Health at the Council on Foreign Relations. Scott Rosenstein is a research associate at the Council on Foreign Relations.
Addressing the UN General Assembly Special Session on HIV/AIDS in June 2001, UN Secretary-General Kofi Annan declared, “For there to be any hope of success in the fight against HIV/AIDS, the world must join together in a great global alliance.” Earlier, in September 1995, US President Bill Clinton’s Committee on International Science, Engineering, and Technology designated infectious disease as a threat to national security. By the turn of the century it seemed possible that years of neglecting the surging HIV pandemic and other lethal infectious diseases might be reversed. Large-scale initiatives from multilateral agencies, deep-pocketed foundations, and the US government infused hope into an area that has historically been underfunded and overshadowed.
But today the optimism is dangerously close to slipping away. Now that real money is on the table, the entire global health effort seems to be descending into bureaucratic and economic quicksand similar to that which has trapped other international development programs for decades. Programs are competing with each other, and key donors are shying away from the multilateral Global Fund in favor of bilateral programs. Implementation of the World Health Organization’s (WHO) program to put three million people on life-saving HIV/AIDS treatment by 2005 is proving staggeringly difficult and demoralizing for much of the WHO staff. US President George W. Bush’s Emergency Plan for AIDS Relief (PEPFAR) has become so highly politicized that its achievements are obscured by controversy. Similarly, the Global Fund has become a lightning rod for debate regarding nearly every aspect of public health funding and implementation. Tuberculosis experts, having long struggled to implement so-called Directly Observed Therapy using very cheap drugs for only months per patient, now shake their heads and say, “I told you so: the drugs are not the issue; it is the infrastructure.”
The approaches and effectiveness of the major players in the global health arena must be reexamined. As these efforts move forward, new avenues of communication and cooperation must be established to mitigate current obstacles while capitalizing on new opportunities.
The Problem
It will never be possible to create a disease-free world or to eliminate the potential for the emergence of new deadly microbes. Policies aimed at such goals will always fail. For example, scientists now understand that the Ebola virus is an ancient organism that has for centuries infected isolated individuals in central Africa. That cannot be stopped. But scientists also understand that Ebola epidemics have occurred when individuals infected with the virus entered desperately poor hospitals, where dearths of sterilizing equipment and basic protective gear conspired to offer the virus spectacular opportunities for transmission. Inadequately supplied hospitals act as disease amplifiers, giving the isolated infection opportunity to become a full-blown epidemic.
With very few exceptions, the disease amplifiers in the world today are manmade and therefore humanly controllable. Within health systems, they include lack of infection control in hospitals, reuse of syringes, and unscreened blood supplies. More broadly, exotic animal markets, unclean urban water supplies, lack of proper sewage systems, and unstable, conflict-ridden environments provide excellent breeding grounds for infectious diseases to spread and wreak havoc on already vulnerable populations. Yet it would be shortsighted to think of infectious disease as a problem for solely the poor and powerless. These diseases do not discriminate; they are undeterred by state borders, party affiliation, or socioeconomic status. With air travel and human migration on the rise, so too is the possibility that deadly microbes can and will circumnavigate the globe with speed and precision.
Global health investment is therefore an issue not only for do-gooders. A self-interest component to the global health debate has clearly emerged—thankfully, because purely altruistic efforts often fall short of international support and sustainability. The interconnected nature of the world makes ignorance of issues such as deadly infectious diseases not only immoral, but self-destructive. This argument is neither new nor unique. However, for much of the last century, the health community scrambled to get access to small amounts of funding to prevent and treat malaria, tuberculosis, HIV/AIDS, vaccine-preventable illnesses, and a host of other killers, even as leaders in the wealthy world declared microbial threats were, from their standpoint, conquered. It has long been argued that detailed, multilateral global surveillance efforts are imperative to stem the global spread of deadly diseases. But when epidemics of Ebola, nipah, hantavirus, and other deadly diseases broke out in the early and middle 1990s, WHO and the US Centers for Disease Control (CDC) had to go begging for funds for scientists’ plane tickets and laboratory supplies. Disease surveillance was haphazard at best.
It would be impossible to reverse the rising death toll of HIV/AIDS without attacking its partner diseases, most significantly tuberculosis. HIV-weakened immune systems make individuals more susceptible to tuberculosis. WHO estimated in 2004 that tuberculosis accounted for approximately 13 percent of AIDS deaths worldwide. “The world has made defeating AIDS a top priority. This is a blessing. But tuberculosis remains ignored,” warned former South African President Nelson Mandela at the 2004 Bangkok AIDS meeting. The window of opportunity to control tuberculosis is closing as drug-resistant forms of the bacterium emerge all over the world. We now have drugs that can cure non-resistant forms of tuberculosis infection for as little as US$10 per patient in developing countries. Yet, Mandela noted, a very simple and inexpensive strategy for control and cure of tuberculosis has been failing in much of the world, pilloried by funding shortfalls and desperately inadequate health infrastructures.
Lack of funding and infrastructure has, in turn, created human resource shortfalls that have nearly crippled the capabilities of institutions endeavoring to create sustainable programs that can be administered with local participation and ownership. A “brain drain”—or, better put, “talent drain”—is removing health professionals from already understaffed programs and countries. A 2004 report from the Joint Learning Initiative, a research group of more than 100 global health scholars and practitioners, estimated that Africa needs approximately one million more health care workers to deliver adequate care to its people. The report draws attention to the massive flow of experienced health care workers in developing countries who are leaving their homelands to find better paying jobs in the developed world—where health care workers are also in short supply.
To the Rescue?
With a mix of volunteerism, elbow grease, and paltry funds, public health advocates the world over did their level best to hold back the rising gap in life expectancy between rich and poor nations and control infectious disease outbreaks. Slowly, recognition began to build and key decision-makers began to see the value in tackling several pressing global health issues.
Under the leadership of economist Jeffrey Sachs, a team of economists and scientists pulled together an historic Macroeconomics of Health report, not only calculating the costs of dozens of infectious diseases, but also putting price tags on their prevention and treatment. The Clinton Foundation and Doctors Without Borders successfully negotiated prices for Highly Active Antiretroviral Therapy (HAART) for HIV/AIDS patients from generic manufacturers down to the point where it seemed possible to treat an HIV/AIDS patient for less than US$200 per year. Patent drug manufacturers responded by bringing down the prices of their drugs as well. To support this effort, more than 100 of the world’s most powerful corporations combined forces, creating the Global Business Coalition to fight HIV/AIDS. The Bill and Melinda Gates Foundation alone has committed hundreds of millions of dollars towards health interventions around the world.
In 2001, after Annan’s call for between US$7 and US$10 billion annually to address selected infectious diseases and the Group of Eight leaders’ in-principle endorsement of those funding levels, there was a noticeable shift. The Global Fund to Fight AIDS, Malaria, and Tuberculosis was created, offering an independent, accountable mechanism for funneling money from the wealthy world to the poor. The Global Fund was envisioned as an institution that could capitalize on the capabilities of both the private and the public sector to overcome the drawbacks of both. On the heels of the establishment of the Global Fund, WHO Director General Lee Jong-Wook ostensibly staked his new leadership of WHO on “3x5,” a campaign to get HAART to three million people in poor countries before the end of 2005.
For much of its existence, the World Bank took the position that economic development would naturally create improvements in health but rejected the converse notion that investment in the health sector would produce economic gains for the developing world. The World Bank had a change of heart regarding investment in the health sector: it recently began implementing its Multi-country HIV/AIDS Program for Africa and has become the largest overall funder of health-related programs in the developing world.
In 2002 the Bush Administration decided to pursue a program, PEPFAR, to combat AIDS largely on a bilateral basis in 14 countries. PEPFAR eventually added a 15th country, Vietnam, to its list of African and Caribbean nations. Its target is treatment of 200,000 people by June 2005.
The Results
Despite all these efforts, more people died of tuberculosis, malaria, and HIV/AIDS in 2003 than in any year in history. Drug resistance threatens the 20th century’s successes in battling a range of bacterial and parasitic diseases. Combined, these killers are continuing to reshape societies, producing dramatic demographic changes that threaten local, regional, and global stability. To be sure, it is still early for many of these initiatives. But the prognosis is not improving.
From a programmatic standpoint, many of the current infectious disease treatment and prevention efforts appear very narrow in focus, failing to consider the interconnected nature of these diseases. Tackling only HIV/AIDS without proper attention to tuberculosis means ignoring the number-one cause of HIV/AIDS-related death and allowing continued community spread of tuberculosis. Creating stand-alone HIV/AIDS clinics risks further stigmatizing individuals who visit these clinics, especially in societies that do not discuss HIV/AIDS openly and shun those known to be HIV-positive. It seems the exceptionalism of the international community’s approach to HIV/AIDS may ultimately reduce its likelihood for success and community acceptance.
Worse, there is a glaring lack of available institutional mechanisms capable of organizing and executing the ambitious programs currently being proposed or underway. The result is consistent interagency conflict: agencies are often either repeating others’ work or competing for resources. Health programs are fighting over poor countries’ dwindling pools of health professionals, bogus generic drug makers are knowingly selling poor products, ministries of health are sitting on, or siphoning off, millions of dollars in unspent donor funds for vital programs. Fighting over what remains an inadequate pool of funds for all has led many leaders and donors to complain that too much money is going to one health drive over another. Questions of patent rights versus generics, abstinence versus condoms, treatment versus prevention, faith-based versus secular initiatives, research versus implementation, and a host of other false dichotomies have overwhelmed these health debates.
In poor countries, the sudden plethora of health programs has spawned a seemingly endless stream of donor-mandated forms and a similarly large number of studies to conduct in order to demonstrate implementation and offer accountability. Simply keeping track of the demands of divergent benefactors requires the time and professional skills of a small army of English-speaking paper-pushers. The campaign to treat HIV-positive people with HAART threatens to devour the health talent of entire nations, undermining everything from child immunization programs to control of other sexually transmitted diseases.
Even with the influx of money into global health, key institutions are still struggling to make ends meet. WHO, with a core program budget just exceeding US$400 million, suffers from chronic under-funding. The institution is also suffering from an identity crisis as it struggles to continue providing technical oversight while rolling out its own ambitious large-scale projects such as the 3x5 program. The strain of this dual responsibility is beginning to show. WHO officials reported that the program was “just short” of the July 2004 treatment goal of 500,000, laying claim to all the estimated 440,000 people in the poor world now on the drugs. The likelihood that they will meet their target of three million people on antiretrovirals by the end of 2005 appears to be dwindling. Failure would be a substantial setback that could threaten donor and government confidence levels in WHO and current HIV/AIDS efforts in general.
The Global Fund also finds itself unable to meet its fiscal responsibilities. It has fallen far short of the US$8 billion donation requirements recommended by the WHO Commission on Macroeconomics and Health. To date, the Global Fund has committed only about US$900 million for its next round of grants to poor countries and nongovernmental organizations, though it has received more than US$3.6 billion in applications deemed scientifically sound. Disbursement delays have also hamstrung this fledgling organization. In a 2004 study by Ruairí Brugha and others in the Lancet, all four of the countries surveyed in sub-Saharan Africa cited as one of their main concerns “delayed disbursement of funds and difficulties in managing evolving Global Fund processes.” They also noted that “high expectations of rapid funding, when grant approval the previous year had received much national media attention, led to a crisis of expectation.”
Part of this funding shortfall can be attributed to the wealthy world’s lack of commitment. EU countries, as well as the United States, have failed to meet their responsibilities to the Fund. The Bush Administration argues that it has given more money to the Fund than any other country—US$683 million since 2001—and has indicated willingness to give more so long as the United States does not donate more than one-third of all contributions in a given year. In contrasting US contributions to the Fund with those of other nations, the US Department of Health and Human Services recently insisted that a US twelve-month fiscal year’s worth of donating be compared with just nine calendar-year months’ worth of EU contributions, drawing the ire of Europeans.
The United States prefers to focus on its own bilateral HIV/AIDS programs. As currently conceived, PEPFAR will treat two million people and provide other types of care to ten million by the end of 2008. As of September 2004, PEPFAR has actually spent 1.2 percent of its funds, directly providing treatment to 18,800 people.
For much of its existence, PEPFAR has been mired in fights over whether its dollars could be spent buying cheap generic drugs versus US-patented products, over condom promotion versus abstinence, and over how best to mete out funds through a laundry list of competing federal agencies (among them the CDC, the US Agency for International Development (USAID), the National Institutes of Health, and the Department of Defense). In a sense, PEPFAR is a global treatment access entitlement program. To the degree the United States continues to go it alone, the burden for maintaining the health of hundreds of thousands of people around the world will rest on US taxpayers for years, quite possibly decades, to come—a burden born, moreover, by a US populace that is decreasingly likely to have health insurance or be able to afford medications for itself. The foreign policy implications of stopping funding—in essence, committing medical murder—are obviously profound.
Congressional whims aside, should there be regime change in a recipient country, the United States would face a critical moral and political dilemma. The appropriations bill allocating FY2004 PEPFAR money stipulated that a third of prevention and education funds had to be spent on abstinence-promoting programs, none of the money could buy sterile syringes or needles for IV drug users, and faith-based organizations should receive special priority for receipt of treatment funds. Any organization or US program thought to promote access to abortions, or to chiefly promote birth control and condom use, has lost US government funding and support. In Uganda, for instance, the government claims HIV “prevalence” dropped from 30 percent in 1990 to 5 percent today. President Yuweri Museveni, signaling his allegiance to the Bush Administration, told the 2004 International AIDS Conference that the key to success was a campaign that pushed abstinence before marriage and fidelity after marriage. That no doubt helped, but the country’s only long-term study shows the number of new infections in southern Uganda dropped by about 40 percent between 1990 and 2002 without any significant changes in general sexual behavior. The only factor that changed, according to the study, was the increase to an 80 percent rate of condom use between casual sex partners.
Even the US Congressional General Accounting Office’s recently released report cites the Bush Administration’s programmatic restraints as an obstacle to PEPFAR’s success. Politicians may not like the idea of handing out sterile needles to heroin users, for example, but such a program in New York City pushed HIV among drug injectors down from a 1990 high of 50 percent to 15 percent in 2002.
Though PEPFAR funds are meant also to address tuberculosis and malaria, USAID cannot explain how it spends most of its tuberculosis and malaria money. In September 2004 testimony to the House Committee on International Relations, USAID representatives indicated US$65 million was spent in FY2003 for malaria efforts but could specify only US$4.2 million in purchases of anti-malaria bednets. The remainder was unaccounted for.
All the while, new infectious diseases, such as Severe Acute Respiratory Syndrome (SARS) and “Mad Cow,” continue to surface. Globalization ensures many more microbial surprises lurk in the future. The emergence of humanly transmissible strains of avian influenza, or “bird flu,” poses the very real possibility of a 1918-type flu pandemic, which killed between 20 and 50 million people in 18 months, including nearly 700,000 in the United States, and circumnavigated the globe in four months, infecting one-fifth of the global population. Although pharmaceutical improvements in treatment and vaccine possibilities offer hope that such a deadly flu strain might be controllable, grave concerns remain: the drugs have limited efficacy even under conditions of ideal use and supplies are limited. Worse, the United States can manufacture only enough vaccine, even under emergency conditions, to protect some citizens, and most of the world lacks any capacity to manufacture vaccine. In a pandemic, the United States would face the foreign policy implications of denying vaccines to billions of people while saving the lives of some of its own. WHO conservatively estimates, even with widespread vaccine and drug use, this pandemic could potentially infect up to 30 percent of the world’s population of six billion people, with approximately seven million deaths.
The Next Steps
The international community does not have its eyes on the right ball. HIV/AIDS is a devastating pandemic that requires a massive global campaign to reverse its course of societal destruction. But HIV/AIDS does not exist in a vacuum. It is impossible merely to reverse the course of the HIV/AIDS pandemic without addressing its companion epidemics of malaria, hepatitis, tuberculosis, and pediatric illnesses associated with orphans exposed to HIV.
One way forward is to integrate the prevention, diagnosis, and care of these interconnected diseases. The diagnosis and testing for all of these diseases would be matters of life-saving routine. Basic research would go hand-in-hand with treatment programs, not shoved to the side as an inconvenient impediment. Prevention and treatment of any particular disease would not be segmented off from others because of jurisdictional boundaries of a certain UN agency, US federal bureaucracy, or international program. Buttressing these efforts must be an infectious disease surveillance system that can synthesize well-founded data from around the world to stem potential scourges (such as SARS and avian flu) before they escalate to overwhelming, not to mention expensive, epidemics. The only way truly to achieve this is through comprehensive integration and communication.
Compartmentalizing HIV intervention programs has, from the beginning, reduced its potential for success. The only effective and sustainable way to reverse the course of the HIV/AIDS pandemic and its companion epidemics is to de-exceptionalize it. Stand-alone HIV prevention and care clinics should not exist. HIV and tuberculosis ought not to be treated as stigmatized outlier syndromes. Syphilis, gonorrhea, hepatitis C, pediatric dysentery—all must come under one tent. And in building that tent the world needs to recall that nearly 75 percent of global wealth is now in the hands of just nine nations, according to 2003 World Bank data. Combined, the poor countries of the world, representing the majority of the population, possess less than one percent of global wealth. By necessity, building a health tent must mean attracting funds from the wealthiest nine states to the needs of the poor, on a massive and sustained level. Given the scale of the challenge, coupled with the constant emergence of new disease threats and potential for manmade scourges, the key for policymakers is to build alliances, work with and strengthen existing multilateral agencies, and avoid bilateral approaches that can undermine and alienate members of the international community.
Local support for these programs is also imperative. This support is two-pronged: community acceptance for the programs being administered is necessary for their success, as are human resource support systems to make the programs sustainable after the international community departs. Integrating services and de-exceptionalizing HIV will go a long way to minimize the stigmatization of this disease and increase community “buy in.” To begin to repair the human capital issues, the obvious yet daunting answer is to lessen the developed world’s demand for foreign health care workers while creating incentives for developing countries’ health workers to stay home. These changes will not occur overnight, but even a gradual shift away from the current trends can make a substantial difference in program effectiveness and begin to reinforce the local confidence level that has been eroded by years of failed promises.
Strengthening multilateral institutions, building local capacity, and improving communication and coordination between agencies will not be an easy task. Humanitarian and development agencies are not known for their ability to play well with others, and many world leaders continue to deny the global catastrophe that is waiting for them if they continue to neglect the need for focused and realistic infectious disease interventions. In contrast to their relatively low ranking on foreign policy priority lists, these issues represent an immediate threat to the security and stability of both the developed and the developing world and can no longer be overlooked.
© 2003-2006 The Harvard International Review. All rights reserved.

5/16/08 Public Health Paper

2008-05-16T06:54:00.000-07:00

A Global Public Health Concentration Proposal

A Project of the 2007-2008 Senior
Global Ambassadors

Christen Bain
Christopher Bettis
Meghan Flemming
Kelsey McGarvey
Cammeo Medici
Table of Contents

Global Public Health at other Higher Education Institutions............................................. 3
Bibliography of Resources.................................................................................................. 6
Experiential Learning and Internship Opportunities......................................................... 16
Funding Sources................................................................................................................ 18
Career Options................................................................................................................... 20

Global Public Health at other Higher Education Institutions

Undergraduate Programs:

University of California at Berkeley
Undergraduate Major in Public Health
- Requires study in Biological Sciences, Mathematics, Social Sciences, and Public Health
- Electives in Biostatisics, Infectious Diseases, Epidemiology, Environmental Health Sciences, Community Health & Human Development, and Health Policy & Management (students are encouraged to concentrate on one or two areas)
http://sph.berkeley.edu/degrees/undergrad.html

Emory University
Undergraduate Minor in Global Health, Culture, and Society
- Core classes on Global Health and Global Health Issues (course outlines available on website)
- Four approved elective courses must be taken in at least two different departments.
- Elective courses that have a major focus on social, economic, environmental or other aspects of global health offered by a variety of Emory College departments are identified and approved by the program prior to each semester
http://www.emory.edu/CHCS/p_UndergradCurricul_Goals.htm

Georgetown University
Bachelor of Science in International Health
- First year courses in health sciences and humanities with introductory courses in epidemiology, population health, disease prevention, and normal nutrition
- Junior year classes focus on microbiology, globalization, global patterns of disease, ecology of global hunger, etc.
- Internships, study abroad, & field trips are encouraged
International Health Certificate
- Three required core courses
- Requires service learning
- Option of elective courses, independent study, or foreign language focus
http://nhs.georgetown.edu/academics/BSIH.html

Michigan State University
Specialization (Concentration) in Global Public Health and Epidemiology
- Designed to be completed by taking one course per semester for seven semesters (3 1/2 years)
- Credits are required to complete the specialization (5 Epidemiology courses, 1 Statistics course & 1 Philosophy course)
- Courses are arranged in a set sequence in which pre-requisites are listed first
http://www.epi.msu.edu/sgphe/index.htm

University of Virginia
Global Public Health Minor
- Six courses (18 credits), which includes a capstone course with a major writing requirement; one internship/field placement; and an additional language requirement
- Students are expected to do a health-related field-placement or service project in either a global or local setting. Normally, such fieldwork will not carry academic credit. For in-depth projects that have academic or research dimensions, students may work with faculty to seek academic research or independent study credit for the field placement. Field placements generally should be between 80-120 hours. Students are expected to keep a journal during their field placement.
http://www.healthsystem.virginia.edu/internet/phs/phpp/globalpublichealthminor.cfm

New York University: Wagner
Public Health Policy Minor
- Two required courses (4 credits each)
- 8 elective credits required from two areas
http://wagner.nyu.edu/undergrad/minors.php

University of Iowa
International Studies B.A. with thematic emphasis on Global Health
- Students direct aspects of their own studies by choosing either a geographic OR a thematic emphasis area according to their individual interests
Global Health Studies Certificate
- 25 semester hours of approved courses, which includes 8 semester hours of required core courses and 17 semester hours of approved elective courses from an approved list
- Students must develop and conduct a research project or participate in a study-abroad or in an internship on a global health/environmental health issue, typically in a foreign setting
- Foreign language requirement
- In the semester following the foreign experience, and as a culmination to the certificate program, all students will present their foreign research project results
Global Health Studies Minor
- 15 semester hours in designated Global Health courses. Students are encouraged to take the 8 credits of the core courses required for the certificate plus an additional 7-8 credits of their choosing
http://international.uiowa.edu/centers/global-health/

Graduate Schools with Programs in Global Public Health or Similar Field:

University of Iowa: Master of Public Health
http://www.public-health.uiowa.edu/mph/about/focus_areas/global_health.html
University of Pittsburgh: Certificate of Public Health
http://www.publichealth.pitt.edu/interior.php?pageID=237
NYU: Master’s Program in Global Public Health
http://www.nyu.edu/mph/
Harvard: Master of Public Health
http://www.hsph.harvard.edu/academics/master-of-public-health-program/
University of North Carolina: Certificate in Global Health
http://www.sph.unc.edu/globalhealth/certificate/
George Washington University: Master of Public Health and Graduate Certificate of Global Health
http://www.gwumc.edu/sphhs/academicprograms/programs/MPH_Graduate_Certificate/GH.pdf
Johns Hopkins: Degree programs in International Health
http://www.jhsph.edu/dept/IH/Degree_Programs/index.html
Bibliography of Resources

We have divided this section into the various types of books that might be included. There are overview books to be included in introductory courses, public policy, disease/emergent disease, environment, ethics, and epidemiology resources.
In communication with professors of global public health classes at other institutions, we have obtained class descriptions and sample reading lists from two classes offered at Princeton.

Overviews/Introductory Books

Essentials of Global Health
by Richard Skolnik (Author)
(Amazon)
...Richard Skolnik's Essentials of Global Health is so comprehensive that it will be key reading in international health. In accessible language, he explains why good health is crucial to economic development, what indicators help track changes in global health, and requirements for good health systems. Approaches to solving world health problems must be under pinned by good ethics and human rights guidelines, he says, and local practices and cultures must not be ignored. Skolnik looks in detail at children's and women's health, and at the different challenges of tackling communicative and non-communicative disease in developing countries. He also maps out the key players in global health and looks ahead to future challenges. ---The Lancet, Vol.370, October 27, 2007

Introduction to Global Health (Paperback)by Kathryn H. Jacobsen (Author)
(Amazon)
With a unique emphasis on possible solutions to world health problems, this book addresses all the key issues of global health at a level that is basic enough so that students from a variety of majors can understand the material. It will give the reader: An understanding of biological and social aspects of major global health issues, especially in the areas of infectious disease, nutrition, and environmental health. A knowledge of population groups that are at increased risk of poor health and familiarity with policies and programs designed to reduce health inequalities. A familiarity with global health vocabulary, the basic methods used to assess global health, and the tools to locate and understand additional global health information. The author has included over 170 tables and figures to illustrate important concepts, as well as a supplemental chapter on how to read journal articles. The text is also accompanied by downloadable instructor resources, including PowerPoint slides, a TestBank, and an Instructors Manual with suggested discussion questions and sample syllabi.

Global Public Health: A New Era
by Robert Beaglehole (Editor), Robert Beaglehole (Editor)
(B&N)
Global Public Health: A New Era addresses three major issues: the changing global context for public health; the state of public health practice in developed and developing countries; and strategies for strengthening the practice of public health in the twenty first century. This book is in three parts. The first part has two aims. Firstly, it surveys the complex old and new challenges facing public health practitioners. Secondly, it summarizes the state of health globally using new data based on measures developed by the World Health Organization and other groups to better describe population health status and trends.
Part two presents the first detailed review of the global state of public health. It analyses the public health situation in all regions of the world. Six chapters cover Europe, North and Latin America, and Australia and New Zealand. Three chapters cover China, Sub-Saharan Africa, and South Asia.
The lessons from these chapters are surprisingly similar: the challenges are great; the public heath workforce and infrastructure have long been neglected; and much needs to be done to reinvigorate the practice of public health.
The third section covers several cross cutting themes: the impact of the new public health threat from bioterrorism and its implications for the future of public practice; the developing field of international public health ethics; and the central and neglected role of the public in strengthening the practice of public health. The final chapter summarizes the major themes of the book and explores the opportunities for building the capacity of the public health workforce to respond to the major global health needs. Despite the enormity of the challenges facing public health practitioners, especially in developing countries, the tone adopted in the final section of this book is relatively optimistic.

Critical Issues in Global Healthby C. Everett, MD Koop (Editor), Clarence E. Pearson (Editor), M. Roy Schwarz (Editor)
(Amazon)
In Critical Issues in Global Health, Koop, Pearson, and Schwarz have assembled contributions by prestigious leaders in the area of public health who here share their insights into what they see as the most pressing issues in global health. The editors have grouped the essays into three main parts, covering countries, continents, and the world; organizational landscapes in global health; and organizations, management, leadership, and partnerships. The relatively short chapters address past successes, current challenges, and possible future advances in public health.

Public Policy

Biosecurity in the Global Age: Biological Weapons, Public Health, and the Rule of Law by David Fidler (Author), Lawrence Gostin (Author)
(Amazon)
“Fidler and Gostin have produced the best description yet of the traditional as well as the newly emerging laws, regulations, treaties and policies in international biosecurity. They navigate through a broad range of topics, while lucidly explaining the public health issues of the new biosecurity age.”—Victoria Sutton, Professor and Director of the Center for Biodefense, Law and Public Policy, Texas Tech University, and author of Law and Bioterrorism

International Public Health: Diseases, Programs, Systems and Policies by Michael H. Merson (Editor), Robert E. Black (Editor), Anne J., Ph.D. Mills (Editor)
(Amazon)
Now there is a book that reflects both the scope and depth of challenges in global health and the dynamic nature of the field. By emphasizing diseases, programs, health systems, and health policies, International Public Health helps readers understand the wide range of global public health issues and the various approaches nations adopt to deal with them. International Public Health explores the public health problems facing low- and middle-income countries today, and identifies the three greatest challenges: reproductive health, infectious disease, and nutrition. Containing case studies throughout, and discussion questions at the end of each chapter, this book discusses emerging health systems--their regulation, financing, and management. Illustrates the importance of health on the economic development of a nation, and the reciprocal impact of development on health

A Textbook of World Health: A Practical Guide to Global Health Care by Russell F. Whaley (Author), T. J. Hashim (Author)
(Amazon)
Textbook for public health students. Stresses three main themes in world health: the provision of primary care; the decentralization of health financing and care; health of migratory people. DNLM: World Health.

Disease/Emergent Diseases

Infections and Inequalities: The Modern Plagues
by Paul Farmer
(B&N)
Paul Farmer has battled AIDS in rural Haiti and deadly strains of drug-resistant tuberculosis in the slums of Peru. A physician-anthropologist with more than fifteen years in the field, Farmer writes from the front lines of the war against these modern plagues and shows why, even more than those of history, they target the poor. This "peculiarly modern inequality" that permeates AIDS, TB, malaria, and typhoid in the modern world, and that feeds emerging (or re-emerging) infectious diseases such as Ebola and cholera, is laid bare in Farmer's harrowing stories of sickness and suffering.
Challenging the accepted methodologies of epidemiology and international health, he points out that most current explanatory strategies, from "cost-effectiveness" to patient "noncompliance," inevitably lead to blaming the victims. In reality, larger forces, global as well as local, determine why some people are sick and others are shielded from risk. Yet this moving account is far from a hopeless inventory of insoluble problems. Farmer writes of what can be done in the face of seemingly overwhelming odds, by physicians determined to treat those in need. Infections and Inequalities weds meticulous scholarship with a passion for solutions--remedies for the plagues of the poor and the social maladies that have sustained them.

Millions Saved: Proven Successes In Global Health by Ruth Levine (Author), Molly Kinder (Author)
(Amazon)
Seventeen stories about how efforts to improve health in developing countries saved millions of lives -- and millions of dollars. From polio in Latin America, to measles in southern Africa, to HIV in Thailand, these inspiring case studies show what it takes for global health programs to succeed.

Bird Flu: A Virus of Our Own Hatchingby Michael Greger (Author)
From age-old scourges such as smallpox and tuberculosis to emerging threats like AIDS and SARS, our interactions with animals have always played a pivotal role as a source of human disease. Bird flu is the latest such menace coming home to roost. Leading public health authorities now predict as inevitable a pandemic of influenza, triggered by bird flu and expected to lead to millions of deaths around the globe.
The influenza virus has existed for millions of years as an innocuous intestinal virus of wild ducks. What turned a harmless waterborne duck virus into a killer? In Bird Flu, Dr. Michael Greger traces the human role in the evolution of this virus, whose humble beginnings belie its transformation into a killer mutant strain with the potential to become as ferocious as Ebola and as contagious as the common cold. In the face of the coming pandemic, Dr. Greger reveals what we can do to protect our families and what human society to can do to reduce the likelihood of such catastrophes in the future.
Amid the growing panic surrounding this issue, Dr. Greger takes a sobering look at a deadly cycle and offers a solution to ending it.

Disease and Democracy: The Industrialized World Faces AIDS by Peter Baldwin (Author)
Disease and Democracy is the first comparative analysis of how Western democratic nations have coped with AIDS. Peter Baldwin's exploration of divergent approaches to the epidemic in the United States and several European nations is a springboard for a wide-ranging and sophisticated historical analysis of public health practices and policies. In addition to his comprehensive presentation of information on approaches to AIDS, Baldwin's authoritative book provides a new perspective on our most enduring political dilemma: how to reconcile individual liberty with the safety of the community.
Baldwin finds that Western democratic nations have adopted much more varied approaches to AIDS than is commonly recognized. He situates the range of responses to AIDS within the span of past attempts to control contagious disease and discovers the crucial role that history has played in developing these various approaches. Baldwin finds that the various tactics adopted to fight AIDS have sprung largely from those adopted against the classic epidemic diseases of the nineteenth century--especially cholera--and that they reflect the long institutional memories embodied in public health institutions.

Environment

Environmental Health
by Monroe T. T. Morgan, Joe E. Beck (Contribution by), Darryl B. Barnett (Contribution by)
(B&N)
The third edition of this text features increased global coverage, an updated appendix of environmental organizations, new chapter key terms, and new information on national and international environmental politics, space as an environment, home safety devices, and nuclear energy. Focus is on the human population and the need to control factors that are harmful to human life rather than on just the environmental sciences. The text is useful for students and professionals in community health education, public health, nursing, engineering, medicine, and the environment. Morgan is affiliated with East Tennessee State University. Annotation c. Book News, Inc., Portland, OR

Ecosystem Change and Public Health: A Global Perspective
by Joan L. L. Aron, Jonathan A. Patz, Jonathan A. Patz (Editor)
(B&N)
The purpose of this textbook on global ecosystem change and human health is twofold:(1) to raise awareness of changes in human health related to global ecosystem change and (2) to expand the scope of the traditional curriculum in environmental health to include the interactions of major environmental forces and public health on a global scale."—from the IntroductionEcosystem Change and Public Health focuses on how human health is affected by global ecosystem changes. It is the first textbook devoted to this emerging field, offering a global perspective on research methods and emphasizing empirical investigations of health outcomes in combination with integrated assessment for policy development. The book covers such topics as global climate change, stratospheric ozone depletion, water resources management, and ecology and infectious disease. Case studies of cholera, malaria, the effects of water resources, and global climate change and air pollution illustrate the analysis and methodology. The book also includes a resource center describing places to start searches on the World Wide Web, guidelines for finding and evaluating information, suggested study projects, and strategies for encouraging communication among course participants.

Essentials of Environmental Health by Robert H., Ph.D. Friis (Author)
(Amazon)
Environmental threats are occurring on a worldwide scale. Dramatic pictures of the devastating effects of natural disasters lead the nightly news. Stories of chemical spills and contaminated groundwater, deforestation and suburban sprawl, depleted fisheries and exploding human population, litter the pages of the newspapers daily. National and international policymakers are concerned about the potential impact on the health of the world’s population and on the global environment and, as a result, much progress has been made in informing the public and introducing regulations for the control of these hazards. As the first in the Essential Public Health series, Essentials of Environmental Health is a clear and comprehensive study of the major topics of environmental health including: Background of the field and “tools of the trade” (environmental epidemiology, environmental toxicology, and environmental policy and regulation). Environmental diseases (microbial agents, ionizing and non-ionizing radiation). Applications and domains of environmental health (water and air quality, food safety, waste disposal, and occupational health). In a straightforward, non-technical approach, the author has included many examples and illustrations of environmental health issues. Perfect for the beginning student as well as the experienced health professional, each chapter concludes with study questions and exercises to engage the reader in further study.

Ethics

Global Prescriptions: Gendering Health and Human Rights
by Rosalind Pollack Petchesky
(B&N)
Global Prescriptions is a critical yet optimistic analysis of the role of transnational women's groups in setting the agendas for women's health in international and national settings. The book reviews a decade of women's participation in UN conferences, transnational networks, national advocacy efforts and sexual and reproductive health provision, assessing both their strengths and weaknesses. It critiques the Cairo, Beijing and Copenhagen conference documents and World Bank, WHO and health sector reform policies. It also offers case studies of national-level reform and advocacy efforts and appraises the controversy concerning TRIPS, trade, and essential AIDS drugs. The author takes into account the formidable political and ideological forces confronting global justice movements and also offers a sobering reassessment of transnational women's NGOs themselves and such problems as 'NGOization', fragmentation and donor-dependency. Petchesky argues that the power of women's transnational coalitions is only as great as their organic connection with grassroots social movements.

Global Pharmaceuticals: Ethics, Markets, Practices
by Adriana Petryna (Editor), Andrew Lakoff, Arthur Kleinman (Editor)
(B&N)
Petryna (anthropology, The New Sch.), Andrew Lakoff (sociology & science studies, Univ. of California, San Diego), and Arthur Kleinman (medical anthropology & psychiatry, Harvard) have edited a collection of nine essays that grew out of the 2002 W.H.R. Rivers Distinguished Lectures in Social Medicine at Harvard University. Most of the writers are medical anthropologists, and their subjects deal with various aspects of "the human consequences of pharmaceutical use and their market expansions in cross-cultural and everyday contexts." Essays offer the results of original research as they discuss the global search for human research subjects, the creation of markets to match existing drugs, company/practitioner ties in Argentina, narcotic dependency treatment in France, how the poor access healthcare in urban India, and government policy in providing AIDS antiretroviral treatment in Brazil and Uganda. The editors hope to spur further research into the issues raised, and although their anthology offers a broader view than found in Marcia Angell's The Truth About the Drug Companies, with its clearly academic style, it is not aimed at the same general readership. Recommended for academic and large public libraries.-Dick Maxwell, Porter Adventist Hosp. Lib., Denver Copyright 2006 Reed Business Information.

Community Health in the 21st Century
by Patricia A. Reagan, Jodi Brookins-Fisher, Jodi Brookins-Fisher
(B&N)
Community Health in the 21st Century introduces readers to their roles and responsibilities as members of a global community addressing shared health concerns. This book is the first of its kind to thoroughly explore social, political, economic, and ethical issues associated with community health from a global perspective. The book emphasizes the impact these perspectives have on possible solutions to important health concerns. It addresses environmental issues, school health programs, and unique concerns of community populations such as ethnically diverse people, people of color, the differently abled, older Americans, children, migrants and farm workers, gay men, lesbians, and women. The book acquaints the reader with the roles and responsibilities of community/public health educators, the leading causes of morbidity and mortality in the United States, Healthy People 2010 emphasis areas, and target populations affected by issues of the 21st century. For college instructors and students.

Global Inequality and Human Needs: Health and Illness in an Increasingly Unequal World
by Laurie A. Wermuth
(B&N)
This book uses a critical theoretical perspective to explore the links between social variables like race, class, and gender, and the health of populations around the world. Global Inequality and Human Needs includes case studies from various countries (Russia, Chile, India, Sub-Saharan Africa) as well as the U.S. show the impact of policy on social inequality and health. Sociologists, public health professionals and anyone interested in international health issues.

Understanding the Global Dimensions of Health
by S. William A. William Gunn, P.B. Mansourian, P. B. Mansourian (Editor), Anthony Piel (Editor)
(B&N)
Health care is a basic human right. But as our planet grows smaller, the number of people without even minimal care continues to rise. Understanding the Global Dimensions of Health brings into sharp focus the ethics and multiple questions involved in keeping the world in optimal health-and identifies the massive tasks that lie ahead. Twenty-one internationally known contributors examine the bioethical, sociopolitical and scientific aspects of health, epidemics, aging populations, the double burden of disease, food safety, and other major health concerns of well-being at the international level. And because exporting health care expertise abroad entails more than merely translating what we know, they meet the controversies head-on:
- Are health technologies wisely used? - Can today's medicine coexist with traditional views and cultural practices? - Will the configuration of health resources change as people live longer? - Why are pandemics not controlled better? - Who wins when health systems clash with sociopolitical systems? - Does globalization necessarily mean the westernization and homogenization of care?
Fast changing conditions and recent catastrophic events demand answers to these and similar vital questions. The authors of Understanding the Global Dimensions of Health balance realism, optimism and social conscience in their coverage so health professionals, policymakers and leaders can address them-locally as well as globally.

Emerging Viruses: AIDS And Ebola : Nature, Accident or Intentional? by Leonard G. Horowitz (Author)
(Amazon)
Health professionals and those involved in infectious disease research will find Emerging Viruses startling: Harvard researcher Horowitz's studies gather evidence to conclude that AIDS and the Ebola viruses evolved during cancer virus experiments in which monkeys were infected with viral genes from other animals. Certain to spark controversy, this provides quite a different view of virus mutations and evolution.

Epidemiology

Epidemiology, Updated Edition: With STUDENT CONSULT Online Access by Leon Gordis (Author)
(Amazon)
This popular book applies the author's many years of clinical and teaching experience to make the principles and methods of epidemiology easy to understand and enjoyable to read about. A clear, concise writing style and just the right dose of humor explain the role of epidemiology in measuring disease in a community, estimating risks, and influencing public policy and ethical concerns. Line diagrams, cartoons, and review questions with answers reinforce the text.

Intuitive Biostatistics by Harvey Motulsky (Author)
Designed to provide a nonmathematical introduction to biostatistics for medical and health science students, graduate students in the biological sciences, physicians, and researchers, this text explains statistical principles in non-technical language and focuses on explaining the proper scientific interpretation of statistical tests rather than on the mathematical logic of the tests themselves.
Intuitive Biostatistics covers all the topics typically found in an introductory statistics text, but with the emphasis on confidence intervals rather than P values, making it easier for students to understand both. Additionally, it introduces a broad range of topics left out of most other introductory texts but used frequently in biomedical publications, including survival curves. multiple comparisons, sensitivity and specificity of lab tests, Bayesian thinking, lod scores, and logistic, proportional hazards and nonlinear regression.
By emphasizing interpretation rather than calculation, this text provides a clear and virtually painless introduction to statistical principles for those students who will need to use statistics constantly in their work. In addition, its practical approach enables readers to understand the statistical results published in biological and medical journals.

Sample Course Descriptions and Reading Lists

Princeton
Infection: Biology, Burden, Policy (SA) Professor(s): Adel A. Mahmoud , Thomas E. Shenk , Burton H. SingerDescription/Objectives:
This course will examine fundamental determinants of human microbe interaction at the biological and ecological aspects. The focus will be on major global infectious diseases, their burden of illness, and policy challenges for adequate prevention and control. Each infectious agent will be discussed in terms of its mechanism of pathogenesis, disease progression, epidemiology, as well as strategies for its control. Specific emphasis will be placed on the public health aspects of each disease.
Sample Reading List:Lederberg, J , Infectious HistoryWeiss, RA & McMichael, AJ , Social and environmental risk factors in the emergence ofinfectious diseases.

Global Health and Health PolicyProfessor(s): Noreen J. Goldman , Alison M. Buttenheim Description/Objectives:
This epidemiology course for undergraduate students in global health and health policy focuses on: measurement of health status, disease occurrence, survival, and the association between risk factors and health outcomes; design, analysis and interpretation of epidemiologic research studies; and bias and confounding. Other topics include synthesis of epidemiological studies, disease outbreaks, causal inference, social inequalities in health, and research ethics. The course will examine "individual-centered" epidemiology and "macro-epidemiology" to assess population impact and inform health policy.Sample Reading List:Leon Gordis, EpidemiologyLouise B. Russell, Educated Guesses. Making Policy about Medical Screening TestKoepsell, Thomas D. and Noel S. Weiss, Epidemiologic Methods: Studying the Occurrence of IllnessJohn Snow, On the Mode of Communication of CholeraR. Doll and A.B. Hill, Mortality in Relation to Smoking: Ten Year's ObservationsR. Kirschstein, Largest US Clinical Trial Ever Gets Under Way

Experiential Learning and Internship Opportunities

As part of the concentration, we would like for students to have the opportunity (or requirement) to do an experiential learning experience whether it be in Des Moines or elsewhere. This experience would help students better understand the various fields within Global Public Health that they might be interested in after graduation for career or graduate study.
We have compiled here a number of different possibilities. Some involve relationships in Des Moines that need to be cultivated and some are already set up, standardized options. Most are paid, but there are some that have the option of working out a credit arrangement (as noted).

Des Moines and Iowa

World Food Prize: George Washington Carver Internship.
Unpaid, but can be credit. 12-15 hrs/week. http://www.worldfoodprize.org/about/Carverinternship.htm

La Clinca de la Esperanza.
Sheryl Gutierres from Drake Pharmacy. Sheryl.Gutierres@drake.edu (needs to be developed)

Iowa Department of Public Health-Office of Multicultural Health (minority health program and refugee health program).
Minority Health Program has internship opportunities; never have had anything in Refugee Health Program, but is a possibility to be explored. Janice Edmunds-Wells jwells@idph.state.ia.us

Polk County Health Department.
Working with the minority population in immunization clinic for green card applicants, etc. Scott Slater sslater@co.polk.ia.us (needs to be developed)

United States (outside of Iowa)

Friends of World Food Programme.
Paid internships ranging from Donor Outreacah to Communications. Mainly for college seniors. Friendsofwfp.org

National Institutes of Health. Summer Internship Program in Biomedical Research.
Paid (>$2,000 per month stipend). For all levels. Internship includes some research as well as lectures. http://www.training.nih.gov/student/sip/

Centers for Disease Control. Student Educational Employment Programs:
Student Careers Employment Program-at least 640 work hours that may lead to CDC job in a field related to academic study.
Student Temporary Employment Program-more flexible program with temporary employment in any field. http://www.cdc.gov/employment/studentjobs.htm#pubhealthtrain

Department of Homeland Security. Customs and Border Control Agriculture Specialist Intern.
2 year internship post-grad $29,000+ Studentjobs.gov

The Washington Center for Internships and Academic Seminars.
Program similar to study abroad, but in the US. Take classes and have a placement in an agency in Washington D.C. You pay tuition (around $10,000 for program and housing fees) and take classes while completing the internship.

International

Internships:
International Fund for Agricultural Development.
Paid 6 month internships ($600/month) in Rome. http://www.ifad.org/job/intern/index.htm

United Nations Environmental Programme.
Paid 3-6 month internships. Variety of areas. http://www.unep.org/vacancies/default.asp?vac_level=Interns

Study Abroad Options: (coordinated with Jen Hogan jen.hogan@drake.edu)
Drake
Global Public Health in South Africa with Professor DeLaet (Summer 2009)

SIT Programs
Brazil-Public Health and Community Welfare
Kenya-Development, Health and Society
Mali-Gender, Health and Development
South Africa-Community Health
Switzerland-Development Studies and Public Health

CIEE Programs
“Study Argentina” Public Health

IES Programs
Santiago (Chile) Health Studies Summer Program
Funding Sources

As developing new curriculum and projects requires new funding sources, we have compiled here some ideas for places to look for possible funding. Much of this is grant funding through Federal agencies and departments.

http://grants.gov/
A database established by the Federal Government. Contains information on over 1,000 grant programs. Gives grants for a broad range of causes and organizations, including grants that individuals may apply for, which include public health issues.

http://www.federalgrantswire.com/
A free resource for federal grants, government grants and loans. Also contains information on the application process for various grants. A very broad database covering a wide range of subjects. Examples of Public Health grants include grants focusing on research, public awareness, and further education.

http://deainfo.nci.nih.gov/flash/frequentused.htm
A resource of the National Cancer Institute (Part of the National Institutes of Health, under the Department of Health and Human Services). Lists 8 major funding areas and the grant resources typically used. Largely aimed at the medical community but may offer resources for students at the levels of public awareness and further education.

http://www.nih.gov/
Website of the National Institutes of Health. Many of their grant opportunities are aimed at the medical community, however they do have some undergraduate and student grants. Most of the subjects any grants or funding would deal with would be applicable to public health. Also has internship opportunities.

The state offices of most Representatives and Senators have staff dedicated to assisting constituents with the federal grant process.

Senator Tom Harkin
http://harkin.senate.gov/
210 Walnut StreetRoom 733, Federal BuildingDes Moines, IA 50309(515) 284-4574 Phone(515) 284-4937 Fax

Senator Charles Grassley
http://grassley.senate.gov/public/
Des Moines 721 Federal Building 210 Walnut Street
Des Moines, IA 50309
(515) 288-1145
Fax: (515) 288-5097

Congressman Leonard Boswell
http://boswell.house.gov/
300 East Locust, Suite 320 Des Moines, IA 50309 Phone: (515) 282-1909 Fax: (515) 282-1785 Toll Free Phone: (888) 432-1984
Career Options

In helping students choose courses for the concentration, we have comiled a list of possible careers that might direct students to a particular area of interest. We hope that this list is not seen as inclusive of all careers involving an education in global public health; rather, a list showing the diversity of careers available. This list will also be useful for students that are considering graduate studies and wish to specialize in any particular area.
The careers have been broken down into different areas including Health Policy and Management, Epidemiology, Biostatistics, Behavioral Science and Health Education, Health Communications, Environmental Health Sciences, International and Global Health, Public Health Preparedness and Function, and Family Health.

Health Policy and Management
Academic Policy Advisor
Legislative Policy Advisor
Management Policy Advisor
Hospital/Managed Care Administrator, Health Facilities
Program Evaluation & Planning, State Health Dept.
Information Systems Manager, Industry/Corporate
Health Services Research Analyst, University
Policy Analyst, Federal Government
Epidemiology
State Epidemiologist
Research Epidemiologist
Pharmacoepidemiologist
Director of Infectious/Chronic Diseases, Local/State Health Dept.
Outcomes Researcher, Industry/Corporate
CDC Investigator, Federal Government
Biostatistics
Data Management Director, State Health Dept.
Director of Clinical Trials, Industry/Corporate
Program Evaluation Analyst, Federal Government
Behavioral Science and Health Education
Behavior Scientist
Health Educator
Mental Health Researcher
Consumer Information Director, Voluntary Health Agencies
Program Planning & Evaluation, Local Health Dept.
Health Promotion Specialist, Industry/Corporate
Health Communications
Communications Specialist
Journalist
Environmental Health Sciences
State Environmentalist
Federal Environmentalist
Waste Management Specialist, Local Health Department/Environmental Agency
Pollution Control Program Director, State Health Department/Environmental Agency
Industrial Hygienist, Industry/Corporate
EPA Researcher/Administrator, Federal Government
International and Global Health
Reproductive Health Specialist
International HIV Specialist
Tropical Disease Specialist
Public Health Preparedness and Function
State Epidemiologist
Laboratory Director
Public Health Lawyer
Family Health
Local Health Officer
Nurse Educator
Nutritionist
Post Presentation Addendums

In looking at the GPH programs at other institutions: think about what programs are at public or private schools as well as whether these institutions have med schools that classes are borrowed from.

In the Bibliography, include Laurie Garrett’s books.

In experiential learning, look at opportunities in Insurance. Also, explore further relationships that the pharmacy school has.

In funding, look at the availability of private funds.

In career options, include careers in insurance, advocacy, fundraising. Pfizer sites were the resources. As well as the career options book published by Pfizer.

Research Subcommittee Report

2008-05-15T06:49:00.000-07:00

Research Subcommittee Report:

General Purpose: Perform research on public health and global health issues.

Chair: Rahul Parsa

The Research Committee has identified the following research tracks:

1. Medical Education Research – relationship between nutrition, culture, and community. The underlying principle being that we can’t look at nutrition in isolation but in unison with culture and society. In this context, ISU’s program in Uganda will provide an ideal research site (see: www.srl.ag.iastate.edu). It is predominantly community engagement in nature (for community based nutritional and health workers, supported by its partner NGO staff and DMU medical students). ISU is already moving forward building on two research projects conducted in 2007.

Iowa has sister city relationships with several countries. Could we select one of those relationships for a project with research embedded? Or could we take an existing relationship of one of the consortiums institutions, to do a project with research?

2. Impact of the Educational Programs of the consortium – Identify Benefits? Opportunities? What worked well, what didn’t work so well? Collectively, what is the impact for Iowa? What are the future consortium implications?

3. Promoting undergraduate or student research (see http://www.drake.edu/dusci/) – should be an important scholarly activity of faculty in public health. ISU’s Uganda program provides such an opportunity. It is conceivable that with this project one could integrate a study abroad component. As a result, students will benefit in three different ways – study abroad, research, and cultural experience.

The committee does not consider the options to be mutually exclusive.

Funding: Option 1 is the traditional research and thus easier to secure funding. The third option is unique in that it has three components. Added to that we are consortium, might give us an opportunity for funding.

Questions:

1. Focus? One country/program or several countries/regions.

2. What should be our research emphasis? In particular, which track?

3. ???

paper

2008-05-06T08:45:00.000-07:00

Population Health in a Globalized World:
How the Future will not be like the past … and why it matters
Ted Schrecker (tschrecker@sympatico.ca)
Institute of Population Health, University of Ottawa, Canada
Presented at Annual Convention of the International Studies Association
San Francisco, March 2008
DRAFT ONLY: This paper is a work in progress. Comments are actively encouraged, but
please do not quote or cite without the author’s agreement
1. Introduction: The Best of Times, the Worst of Times?
Today’s world is characterized by dramatic disparities between the health of people in rich and
poor countries. In Canada, just six children out of every 1,000 can expect to die before the age
of five; in the low-income countries where 2.4 billion people live, the figure is 114 children out
of every 1,000. In Canada, the lifetime risk that a woman will die from complications of
pregnancy and childbirth is one in 11,000; in Niger, one of the world’s poorest countries, it is
one in seven (Say, Inoue, Mills & Suzuki, 2007).
Many such disparities can be traced to economics, starting with access to health care.
Low-income countries spend just $24 per person per year on health care, while in high-income
countries the figure is almost $3,700 (Health, Nutrition and Population Group; accessed Dec. 31,
2007). Although the importance of access to health care must never be underestimated, it is just
part of the picture. Emerging understandings of social determinants of health – conditions of life
and work that make it relatively easy for some people to lead long and healthful lives, and all but
impossible for others – show that inequalities in access to health care are strongly congruent
with health-destroying lack of access to other basic needs. According to United Nations figures,
more than 800 million people are chronically undernourished, and the World Bank estimates that
roughly a billion people live in absolute poverty. The interaction of multiple forms of
deprivation underscores the wisdom of the observation “that many of the most devastating
problems that plague the daily lives of billions of people are problems that emerge from a single,
2
fundamental source: the consequences of poverty and inequality” (Paluzzi & Farmer, 2005): 12).
The development, poverty reduction and global health agendas therefore should be regarded as
inextricably linked and interdependent.
Some reassurance can be found in recent policy developments. According to UNAIDS,
in just the three years from 2003 to 2006, the estimated number of people receiving ART in lowand
middle-income countries quintupled, from 400,000 to just over 2 million; in sub-Saharan
Africa, where the need is greatest, the number of recipients of ART increased 13-fold (UNAIDS,
2007). This is a success story the life-saving significance of which must not be neglected.
Development assistance for health rose from approximately $2 billion in 1990 to $12 billion in
2004, the most recent year for which figures are available (Schieber, Fleisher & Gottret, 2006).
Reassurance could be found, as well, in adoption of the Millennium Development Goals and
associated targets: “the world’s biggest promise” (Hulme, 2007). Three MDGs are explicitly
health-related, and four others directly address crucial social determinants of (ill) health. In
2005, two high-profile syntheses of research evidence on development policy each called for an
approximate doubling of development assistance spending in order to improve the prospects for
achieving the MDGs (Commission for Africa, 2005; UN Millennium Project, 2005). At the very
least, these two reports and Sachs’s subsequent analysis of the savage arithmetic of government
budgeting in low-income countries (Sachs, 2007) should have lifted the burden of proof from
those who advocate increased resource transfers from rich countries to poor, placing it instead on
sceptics who invoke the limited “absorptive capacity” of recipient countries or insist that health
systems and social provision must be “sustainable” in the sense that they do not rely on external
resources. The Millennium Project, in particular, went further: for instance, linking “poverty
traps” that inhibit national development to such macro-level variables as the continuing
inadequacy of external debt cancellation and lack of developing country access to export markets
in the industrialized world. Establishment of the Commission on Social Determinants of Health
(CSDH) by the World Health Organization (WHO) in 2005, and the Commission’s focus on the
explicitly normative concept of health equity, can be read as indicating a long-overdue
recognition that the Organization must move beyond the biomedical model and the provision of
advice by physicians to active engagement with social and economic policy, in the spirit of its
much-neglected constitutional and historical commitments (Brown, Cueto & Fee, 2006).
3
On the other hand, I still spend a great deal of time slowly and carefully explaining why
poverty, however defined, and economic insecurity are hazardous to health, to people who are
themselves at zero risk of those conditions. (I do not repeat the explanation here.) After
development issues, African development in particular, occupied centre stage at the G8 Summit
in 2005, they lost much of their salience; a Council on Foreign Relations Task Force commented
approvingly in 2006 that, post-Gleneagles, “humanitarian interests” have been supplanted by
such concerns as energy security and terrorism. If these aren’t invoked, the Task Force warned
ominously, it will be “exceedingly difficult, in the face of growing budget pressures in the
United States, to maintain and deepen promising commitments for development, HIV/AIDS, and
security initiated in the past several years” (Lake, Whitman, Lyman & Morrison, 2006). (The
fact that those budget pressures exist because of the Bush government’s simultaneous pursuit of
a ruinously expensive foreign war and tax cuts for the ultra-rich went unacknowledged.) Many
recent assessments conclude that the MDGs and associated targets are unlikely to be met, most
conspicuously but not only in sub-Saharan Africa (Wagstaff, Claeson et al., 2003; United
Nations, 2007). The MDGs, while ambitious when viewed against the background of past
development policy, are modest when measured against the scale of unmet health-related basic
needs.1 And in several cases, achieving the Goals on the basis of national averages might still
mean little or any improvement in the situation of the worst-off groups within a particular society
(Gwatkin, 2005; Moser, Leon & Gwatkin, 2005).
Here I do not assess the substantive adequacy of recent efforts to integrate the
development, poverty reduction and global health agendas; these assessments have been
provided elsewhere (see e.g. Schrecker, Labonte & Sanders 2007; Labonte & Schrecker, 2007a;
Labonte, Schrecker & Sanders 2008). Instead, I take a future-oriented approach to the prospects
of those agendas, reflecting on some of the findings and conclusions of the Globalization
Knowledge Network that supported the work of CSDH.2 I start from the premise that
1 The MDG poverty reduction target involves reducing by half between 1990 and 2015 the proportion of
the world’s people living below the World Bank’s contentious $1/day poverty line (actually, about $1.50
in today’s funds). Philosopher Thomas Pogge (2004) has commented on the modesty of this target when
viewed against a background of expanding global affluence. Another MDG target involves improving the
lives of 100 million slum dwellers per year by 2020, yet it is estimated that if present trends continue, 1.4
billion people worldwide will be living in slums in that year (UN Millennium Project Task Force, 2005).
2 I served as Hub coordinator of that Network and was one of the authors of its final report (Labonte et
al., 2007). However, all views expressed here that are not clearly attributed to cited authors are
4
globalization, defined as “a process of greater integration within the world economy through
movements of goods and services, capital, technology and (to a lesser extent) labour, which lead
increasingly to economic decisions being influenced by global conditions” (Jenkins, 2004: 1), is
a central element of the international and domestic policy environment. Sections 2 and 3 of the
paper are primarily descriptive: I argue, based only on a subset of the available evidence, that
what we know about globalization suggests not only a future of increased inequality and
polarization of income, wealth and economic opportunities within and across national borders,
but also serious constraints on policy initiatives that would compensate for globalization’s
polarizing tendencies. Section 4 is more analytical and also more tentative: I consider the
political plausibility of the Globalization Knowledge Network’s core policy prescription for
“redistribution, regulation and rights” as a necessary check on the unfettered operations of the
global marketplace, providing the outlines of an agenda for future research that incorporates not
only the dynamics of globalization at a supra-national level but also the less carefully studied
impact of globalization on changing allegiances and distributions of resources at the level of
domestic politics. Section 5 concludes, rather pessimistically.
2. Is Globalization Good for You?
It has been claimed that “globalization is good for your health, mostly” because countries that
integrate into the global economy more rapidly (e.g. through trade liberalization) experience
more rapid growth and are therefore better able to reduce poverty (Feachem, 2001). This
argument has numerous and well documented weaknesses (for a summary see Labonte &
Schrecker, 2007b). Globally, progress toward poverty reduction remains modest against a
background of unprecedented abundance and the definition of poverty usually adopted for
purposes of measurement, the World Bank’s $1/day and $2/day poverty line, is regarded as
seriously inadequate by many observers (Chen & Ravallion, 2004; United Nations Economic
Commission, 2004: 76; Kawachi & Wamala, 2007). Even using the World Bank’s contentious
thresholds, poverty increased substantially in sub-Saharan Africa during the 1980s and 1990s.
exclusively my own and not those of the Network’s members, the Commission on Social Determinants of
Health, or WHO.
5
Admittedly, some countries such as Vietnam and China have achieved impressive growth
rates and poverty reduction track records while opening their borders to imports and foreign
investment and rapidly deregulating domestic markets. However, they and other fast-growing
Asian economies were selective about the process of economic integration, and retained a
considerable degree of state control over economic development. Conversely the growth
performance of Latin American economies, many of which were the most enthusiastic adopters
of neoliberal economic prescriptions, was weaker after 1980 than during the preceding “era of
import substitution, protectionism, and macroeconomic populism” (Rodrik, 2007), and poverty
in Latin America, measured with reference to actual in-country costs of meeting nutritional
needs, was more widespread in 1999 than in 1980 (United Nations Economic Commission,
2004: chapter 1; Sáinz, 2006). The Chinese and Vietnamese experiences further show that
marketization of the domestic economy has drastically increased the cost of health care, and
reduced accessibility, for much of the population (United Nations Country Team Viet Nam,
2003; Akin, Dow & Lance, 2004; Akin, Dow, Lance & Loh, 2005; Sepehri, Chernomas &
Akram-Lodhi, 2005; Dummer & Cook 2007; Meng 2007). Indeed, economic growth has proved
a remarkably ineffective mechanism for reducing poverty (Woodward & Simms, 2006).
An innovative econometric exercise that studied relations among globalization, growth
and health using data from 136 countries was commissioned for the Globalization Knowledge
Network (Cornia, Rosignoli & Tiberti, 2007). The authors first identified five main influences
on mortality, the most basic (ill) health outcome: material deprivation; psychological stress;
unhealthy lifestyles; inequality and lack of social cohesion; and technical (i.e., medical) progress.
They then identified a range of variables that affect these influences, classifying the variables as
either (a) related to policy choices made in the context of globalization (e.g. GDP growth,
income distribution, immunization rates); (b) endogenous, and therefore unrelated to
globalization for purposes of the analysis (medical progress); or (c), describable as “shocks” (e.g.
wars and natural disasters, HIV/AIDS). The final stage of their analysis consisted of a
simulation that compared trends in life expectancy at birth (LEB, the most basic population
health indicator) over the period 1980-2000 with those that would be predicted based on a
hypothesized counterfactual set of assumptions in which trends in all the relevant variables did
6
not follow the actual 1980-2000 pattern, but rather remained at the 1980 value or continued the
trend they followed over the pre-1980 period.3
The simulation indicated that, on a worldwide basis, over the period 1980-2000 effects of
globalization cancelled out most of the progress toward better health (as measured by LEB) that
was attributable to the diffusion of medical progress. The effects of shocks (wars, natural
disasters and AIDS) combined with globalization to result in a slight worldwide decline in LEB
as compared with the counterfactual. Regionally, the most conspicuous declines in life
expectancy relative to the counterfactual occurred in the transition economies and the former
Soviet Union (where globalization accounted for essentially the entire decline) and sub-Saharan
Africa (where globalization contributed almost as much as the AIDS epidemic to a decline of
nearly nine years in LEB, despite the benefits from medical progress). It can be objected that the
diffusion of medical progress is at least partly a consequence of globalization, rather than an
endogenous variable; in other words, that the analysis overstates the negative consequences of
globalization. However, trends like the decline of access to health care in China and Vietnam
and the stagnation of immunization rates in sub-Saharan Africa, affected by such phenomena as
declining commodity prices, debt crises, and structural adjustment conditionalities, suggest that
the diffusion of medical progress may be occurring in spite of globalization rather than because
of it. Conversely, the treatment of HIV infection as a shock analogous to natural disaster can be
seen as problematic, because of evidence linking vulnerability to HIV infection with
globalization by way of (a) poverty and economic insecurity (Wojcicki & Malala 2001;
Wojcicki, 2002; Schoepf, 2004; De Vogli & Birbeck, 2005) and (b) precarious income increases
experienced in conjunction with global diffusion of Western fashion and consumer goods
(Smith, 2000; Luke, 2005; Stoebenau, 2006; Mishra et al., 2007). Use of life expectancy rather
than more nuanced data on illness and quality of life also introduces uncertainties, although these
are unavoidable given data limitations. The authors admit the problems associated with lack of
data and selection of globalization-related variables and data sets, warning that “the
establishment of a causal nexus between globalization policies and health cannot be but
tentative” (Cornia et al., 2007: 1). Nevertheless, the study represents a highly credible challenge
3 Thus, it was assumed in the counterfactual (for instance) not only that income distribution within
countries, one of the globalization-related variables, did not change over the period 1980-2000, but also
that there was no progress in medical technology and that HIV incidence remained at its 1980 level.
7
to the macro-level story about globalization’s health benefits, notably including those in the
“growth superstars,” India and China (Cornia et al., 2007: 27).
3. “Disequalizing” globalization: labour markets and financial markets
A valuable starting point for this discussion is provided by Birdsall’s observation that “global
markets are inherently disequalizing” and their operations are “asymmetrical” in several ways,
favouring those individuals and countries already well endowed with assets and able to use their
resources to shape the rules of the international economic order (Birdsall, 2006: 18-32) . Birdsall
was primarily concerned with trade policy, but the observation is applicable to all globalization’s
channels of influence. Here I discuss only two: globalization’s transformation of labour markets
and the growing disciplinary power of financial markets. My intention here is not to describe the
full range of pathways by which globalization increases disparities in access to social
determinants of health, which in a preliminary way has been done elsewhere (Labonte &
Schrecker, 2007c), but to combine selective description with an indication of how constraints on
policy initiatives to reduce those disparities may be intrinsic to the processes in question.
A genuinely global labour market is gradually emerging (World Bank, 1995; World
Bank, 2007b), as production is reorganized across multiple national borders, in networks that
now involve not only the multiple subsidiaries and affiliates of transnational corporations
(TNCs), but also contractual relationships with external suppliers and service providers
(‘outsourcing’): what might be called the Nike model (Donaghu & Barff, 1990; Barff & Austen,
1993). The result is an increasingly fine-grained process of “slicing up the value added chain”
(Krugman, 1995) in production networks that locate each step of the process where it contributes
most to overall returns while reducing risks (Sturgeon, 2001). To understand the logic and the
importance of this process contrast it, as Krugman does, with Ford Motor Company’s iconic
River Rouge plant where every step of the process of manufacturing an automobile from
steelmaking to final assembly was carried out at a single location. Today’s automobiles, and
many other manufactured products, are likely to contain components and subassemblies
manufactured in a multitude of countries, often by firms with no relation to the parent company
beyond a time-limited contract (Sturgeon, 2002; Dicken, 2007: 278-346). The World Bank
warned at the end of the 1990s that the “open production environment” created by global
8
reorganization of production “mercilessly weeds out those centers with below-par
macroeconomic environments, services, and labor-market flexibility” (World Bank, 1999: 35-36,
50). Among the centres subjected to such weeding: northern Mexico, which lost some 300
export-oriented manufacturing plants to China between 2001 and 2003 (Anon., 2003). An effect
of particular importance is the concentration of power among firms at the top of buyer-driven
commodity or value chains, which can appropriate much of the value generated in the production
process while forcing suppliers to compete against one another, often on the basis of their labour
costs. This model is most closely associated with the apparel industry, but is also evident in food
production and marketing and with respect to the operations of Wal-Mart, whose business model
is now distinctive enough to be a topic of research in its own right (see e.g. Ross, ed., 1997;
Faiguenbaum, Berdegue & Reardon, 2002; Gereffi, Humphrey & Sturgeon, 2005; Hearson &
Eagleton, 2007; Hays, 2003; Goodman & Pan, 2004; Appelbaum & Lichtenstein, 2007).
In high-income countries, reorganized production and technological change, driving by
investors’ expectations of higher returns, have resulted in a precipitous drop in the demand for
‘unskilled’ workers and in their incomes (Nickell & Bell, 1995). The integration of growing
numbers of people in India, China and the former transition economies into the global
marketplace will roughly double the size of the global labour force. Many observers conclude
that this will mean sustained, worldwide downward pressure on wages (Woodall, 2006; Ferguson
& Schularick, 2007). The World Bank view is more sanguine, holding that wage increases “will
create space for low-income countries to move into the lowest-skill activities vacated by
producers in the large emerging countries” (World Bank, 2007b: 102). Over time, some firms in
developing countries may be able to ‘move up the value chain’ within global production
networks based on sources of competitive advantage that go beyond low wages and flexible
working conditions; firms that once carried out contract manufacturing for producers of namebrand
electronic products may even become their competitors (Arrunada & Vazquez, 2006).
However, it is not clear (to put it mildly) that all firms or countries will be able to pursue such a
strategy successfully (Kaplinsky, Morris & Readman, 2002; Nadvi, 2004) or that even when
firms succeed the benefits will be shared by their workers.
Worldwide, some workers are far more vulnerable than others. Robert Cox has argued
that globalization divides labour forces into a hierarchical structure of “integrated, precarious,
and excluded” workers (Cox, 1999). The usefulness of this typology is confirmed (for instance)
9
by 1997 survey data from Brazil, Chile, Colombia, Costa Rica, El Salvador, Mexico, Panama
and Venezuela showing that “the occupational structure has become the foundation for an
unyielding and stable polarization of income,” with lower income personal service, agricultural,
commercial and industrial workers making up 74 percent of the working population; an
intermediate stratum of technicians and administrative employees 14 percent, and higher-income
professionals, employers and managers just 9 percent (United Nations Economic Commission,
2000: 61-91). Analysis of these data links “the need to participate competitively in the world
economy” to labour market deregulation, increased flexibility, and the growth of economic
insecurity (United Nations Economic Commission, 2000: 93-102). Similar descriptions of
labour market polarization and the associated precariousness of livelihoods can be found in
recent studies of the Asian context (United Nations Economic and Social Commission, 2006;
Asian Development Bank, 2007: 304-311) Indeed the World Bank has projected that despite
optimistic predictions for global growth and the expansion of a global middle class, about which
more later, changes in the opportunities available in labour markets will lead to increased
economic inequality in countries accounting for 86 percent of the developing world’s population
over the period until 2030, with the “unskilled poor” being left farther behind (World Bank,
2007b: 67-100). 4 The next section of the paper raises the question of how this polarization is
likely to affect political allegiances.
Adding to globalization’s disequalizing effects, while the ‘skilled’ and credentialed are
increasingly mobile across national borders, notably within corporate structures, those with
limited education routinely find their options restricted to “survival circuits” of low wage labour,
the end points of which are instantiated by reliance on undocumented Mexican and Central
American workers in parts of the United States, and more generally by the proliferation of deadend
jobs driving taxis, delivering restaurant orders, caring for children and cleaning buildings in
the ‘global cities’ that are the control centres of the world economy (Sassen, 2002; Seifert &
Messing, 2006). Meanwhile, in at least some high-income economies this pattern is
accompanied by rising economic insecurity throughout the labour force and a concentration of
4 The distinction between skilled and unskilled workers is problematic, although it is widely used in the literature,
for at least two reasons: (a) in conventional usage it does not appear to have any clear relation to the complexity of
the tasks involved (Levy & Murnane, 2006), although a notable exception is Grossman & Rossi-Hansberg (2006),
and (b) it focuses attention on characteristics of the individual rather than on the social environment and factors
affecting stratification.
10
labour incomes at the very top of the income scale: the emergence of the “working rich”
(Duménil & Lévy, 2004; see for background Saez, 2005; Mishel, Bernstein & Allegretto, 2007;
Yalnizyan, 2007). Although the extent to which this last phenomenon can be attributed to
globalization is contestable, its influence on the political viability of policies to counter
globalization’s impacts is less so.
Development researchers are familiar with the conditionalities attached to structural
adjustment lending from the World Bank and the IMF, and with the frequently destructive
effects on social determinants of health. Those conditionalities are now complemented, and
sometimes replaced, by “implicit conditionality” created by hypermobile capital in global
financial markets (Griffith-Jones & Stallings, 1995). The size of the resource flows in question
can be understood from the fact that, while the total value of foreign direct investment (to build
new production facilities or acquire existing assets) in 2006 was $1.2 trillion, the daily value of
foreign exchange transactions on the world’s financial markets is now estimated at $3.2 trillion
(United Nations Conference, 2007; HiFX Foreign Exchange, 2007).
The 24/7 global financial marketplace, its effects magnified by a diversity of largely
unregulated financial instruments (see e.g. Erman, McNish, Perkins & Scoffield, 2007), can
generate financial crises like those that affected Mexico in 1994-95, several Asian countries in
1997-98; Argentina in 2001-02 and perhaps a wider range of countries and classes at this writing
(March 2008). Such crises plunge millions of people into poverty and/or the informal economy,
damaging health as income losses lead to undernutrition and reduced access to health care
(Hopkins, 2006). These effects may be compounded by austerity measures needed to reassure
financial markets or the IMF, although considerable inter-country variation is observable in this
respect, and prolonged by the fact that employment recovers much more slowly than GDP in the
aftermath of financial crises (van der Hoeven & Lübker, 2005). The former Managing Director
of the IMF, writing in the aftermath of the Mexican peso crisis of 1994-95, referred to the “swift,
brutal and destabilizing” consequences that ensue when policies are not “deemed basically
sound” by investors (Camdessus, 1995). This blunt observation about the power of markets is
notable for its author as much as for its content, which is now almost universally acknowledged.
Somewhat less spectacular, but perhaps just as important in terms of social determinants
of health, is the effect of financial markets on domestic redistributive policies. Apparently
concerned about policies that might be adopted by the Workers’ Party in Brazil (in advance of
11
the 2002 elections) or the African National Congress in South Africa (after democratization),
investors drove down the value of national currencies by roughly 40 percent in each case,
arguably leading the governments in question at least temporarily to accept high unemployment
and limited social expenditure rather than risk further depreciation of their currencies (Goldfajn,
2003; Evans, 2005; Koelble & Lipuma, 2006). In South Africa, the result was ”dismal
development and excellent macroeconomic outcomes” (Streak, 2004), with the former including
negative employment growth in every year between 1996 and 2000 and an official
unemployment rate of over 30 percent; unofficial unemployment rates, using a broader measure,
were and are considerably higher (Kingdon & Knight, 2005). Layna Mosley, one of the most
accomplished investigators of how global financial markets actually work (Mosley, 2003),
concludes that “those societies most in need of egalitarian redistribution may have, in terms of
external financial market pressures, the most difficulty achieving it” (Mosley, 2006: 90).
Further complicating the picture, it is often difficult to distinguish between the effects of
such external pressures and those of actual or anticipated domestic capital flight – defined by
Beja, 2006 (p. 265) as “the movement of capital from a resource-scarce developing country to
avoid social control,” which can mean taxation, regulation as well as a variety of economic
policies favouring, e.g., productive investment rather than speculation. The Mexican financial
crisis of 1994-95 was generated not only by US investors selling Mexican securities, but also by
wealthy Mexicans who shifted into US dollar-denominated assets in anticipation of devaluation
(US General Accounting Office, 1996). Generically, the capital flight constraint on public policy
is illustrated by John Williamson’s comment that “levying heavier taxes on the rich so as to
increase social spending that benefits disproportionately the poor” is conceptually attractive, but
“it would not be practical to push this very far, because too many of the Latin rich have the
option of placing too many of their assets in Miami” (Williamson, 2004). A discussion of
Chilean social policy to which I return later in the paper notes that fear of capital flight provided
a “powerful constraint on a more vigorous pursuit of the government’s social equality
objectives” between 1990 and 2000 (Teichman, 2008: 450). The constraint is important because
calculations for Latin America, a region where levels of intra-national economic inequality are
persistently among the world’s highest (Hoffman & Centeno, 2003) show that even a little
redistribution of income through progressive taxation and targeted social programs would go
farther in terms of poverty reduction than many years of solid economic growth (Paes de Barros
12
et al., 2002; see also de Ferranti, Perry, Ferreira & Walton, 2004). Although the emergence of
Miami as a regional financial and business centre increases opportunities for capital flight in the
Latin American context, the problem affects developing and transition economies in most
regions of the world (see e.g. Loungani & Mauro, 2002; Ndikumana & Boyce, 2003; Beja,
2006). Needless to say, most people in such economies do not have the option of diversifying
into foreign assets, so access to opportunities for capital flight has a strong polarizing influence
quite apart from the constraints that capital flight imposes on domestic policy.
4. Population health and the possibilities for redistributive social policy
The preceding discussion suffices to make the case (a) that, paraphrasing Birdsall, the problem
with globalization is not market failure but market success, and therefore (b) that without
decisive policy intervention, globalization is likely to lead to increased health disparities by way
of multiple pathways involving economic polarization. Against this background, the
Globalization Knowledge Network borrowed terminology from a followup to the Copenhagen
Social Summit by the Finnish social policy research unit STAKES to call for a generic response
by way of the “three R’s”:
“• systematic resource redistribution between countries and within regions and countries
to enable poorer countries to meet human needs,
• effective supranational regulation to ensure that there is a social purpose in the global
economy, and
• enforceable social rights that enable citizens and residents to seek legal redress”
(Deacon, Ilva, Koivusalo, Ollila & Stubbs, 2005).
What are the prospects for implementing this prescription, within national borders and at the
level of supranational institutions? Multiple research questions need to be addressed; here I
focus here on the prospects for redistributive social policy within countries, keeping in mind that
many of the same political feasibility issues attach to regulation (e.g. of employment relations)
and rights (e.g. to social provision or health care).
Evidence does not support a fatalistic view that globalization simply prevents
implementation of the three R’s. Industrialized countries, including some archetypal small open
economies, vary by an order of magnitude in the prevalence of child poverty (measured using a
standard designed for cross-national comparison); globalization has not precluded diversity of
labour market arrangements and social policies, some of which are highly redistributive
13
(UNICEF, 2005). At the same time, social protection institutions in these countries have been
experiencing pressures for retrenchment. Some evidence suggests that even the most effective of
such institutions have only been able to prevent inequalities in market incomes during (roughly)
the post-1980 period of contemporary globalization from widening (Kenworthy & Pontusson,
2005). In other countries, Canada for instance (Heisz, 2007), the redistributive effect of tax and
transfer programs has decreased dramatically. Further, as Mosley reminds us, financial markets
do not allow most low- and middle-income countries a comparable degree of policy flexibility.
Conversely, constraints on the ability of national and subnational governments to reduce
the destructive impacts of the global marketplace may arise from several sources in addition to
the operation of financial markets, although the prospect of capital flight will often lurk in the
background. The following discussion is highly stylized, but provides a starting point for further
inquiry and the generation of more specific hypotheses.
Many existing regimes of regulation and social provision arose as provisional settlements
of domestic distributional conflicts, mainly although not only those between labour and capital.
Global reorganization of production may free capital from the imperative of negotiating such
settlements at the national level because of the option of relocating production elsewhere,
simultaneously enhancing capital’s bargaining power relative to labour within national
boundaries (Bronfenbrenner, 2000).5 Indeed, strong pressures exist toward economic and social
policy convergence on the ideal type of the competition state, “[t]he main focus of [which] is the
promotion of economic activities, whether at home or abroad, which will make firms and sectors
located within the territory of the state competitive in international markets” (Cerny, 2000: 136).
Cerny draws the provocative analogy with interjurisdictional competition for investment in the
United States, suggesting that national governments, deprived by globalization of many onceeffective
policy instruments, now must compete for investment in a similar way. Against this
argument, it must be stated that a series of cross-national econometric studies failed to find any
statistical support for the claim that globalization, as measured by openness to trade and foreign
direct investment, has negative consequences for institutionalizing core labour rights as
identified by the International Labour Organization; indeed some effects tended to be positive
5 This is one of several weaknesses in the argument that globalization can be managed equitably by way
of a “global social contract”: even if the necessary institutional structures existed, capital has few
incentives for entering into such a contract analogous to those that exist when distributional conflicts must
be resolved within national borders, and many to resist it.
14
(Neumayer & De Soysa, 2005; Neumayer & De Soysa, 2006; Neumayer & De Soysa, 2007).
However, the authors are clear about the limited inferences that can be drawn from their
findings, which cannot be applied to outcomes as distinct from process-related variables. “It is
entirely possible of course, perhaps even likely, that globalisation boosts the bargaining power of
capital at the expense of labour, which would put downward pressure on outcome-related labour
standards such as wages, working times and other employment conditions. These have not been
the subjects of our analyses” (Neumayer & De Soysa, 2007: 1532).
In many low- and middle-income countries globally oriented economic elites (cf. Jones,
1998; Flynn, 2007) are emerging. Their interests are much more closely aligned with those of
their counterparts in the high-income world than with their compatriots’; their fortunes are tied to
alliances with TNCs, and in an increasing number of cases to building them. What happens a bit
lower on the economic pyramid may be just as important. In the study that predicted an increase
in labour market inequalities in most of the developing world, the World Bank envisioned the
emergence of a global middle class: “in 2030 more than a billion people in developing
countries,” as compared to 400 million in 2000, “will buy cars, engage in international tourism,
demand world-class products, and require international standards for higher education.” The
members of this expanding middle class will be globally oriented as consumers, and often in
their relation to the productive process as well. The Bank’s rosy view of the implications for
social policy is that “[a]s average incomes rise, the number of poor will shrink and the tax base
will grow, making effective assistance easier to provide and social safety nets a viable remedy
for increasing inequality” (World Bank, 2007b: 69).
But will the new middle class be willing to share? It would seem unwise to presume this.
A vision at least as plausible as the World Bank’s, lent added credibility by the rapid pace of
urbanization in the developing world, is of a future in which more and more places come to
resemble present day São Paulo, where world-scale wealth and extreme poverty coexist; the
ultra-rich commute by helicopter in order to avoid the tedium of traffic congestion and the
possibility of carjacking; and at least segments of the middle class retreat to fortified enclaves
while enthusiastically supporting criminalization of the poor (Caldeira, 2000; Romero, 2000;
Wacquant, 2003).
A further factor is the diffusion of neoliberal ideology, which is sufficiently central to the
process of globalization that some authors refer to neoliberal globalization or simply to
15
“neoliberalization.” (Harvey, 2005; see also Eide, 2005). Neoliberalization was, and to a
considerable degree continues to be, aggressively promoted internationally by right-wing
governments and key multilateral institutions like the World Bank.6 Harvey (2006) argues
convincingly that it should be understood as a strategy for recapturing class power both
domestically (i.e., within the United States) and internationally. At the same time, ideology
cannot be reduced to its historical origins or congruence with material interests; within domestic
policy contexts it operates in part as an independent variable, conditioning judgments about
feasibility and desirability. Important illustrations are provided by Canadian legal scholars
Fudge & Cossman (2002), who identify multiple dimensions of “privatization” as a set of
assumptions about the appropriate locus of responsibility for social problems and social
provision, and Schild’s more historically grounded analysis of how contemporary Chilean social
policy and the perspectives of civil society organizations reflect an equation of citizenship with
active individual participation (as a producer and consumer) in markets, rather than with
participation in collective choices as a member of a polity. “Neoliberalism is understood here
not just as a political economic reality, but also as a political project intent on re-regulating
society through the rationality of the market and that ultimately depends on techniques for the
self-regulation of individuals” (Schild, 2007: 180).
How do these hypotheses (some would call them conjectures) fit with the available
evidence? Since as stated earlier my primary objective is to explore areas for further inquiry, I
consider only one example: the large-scale conditional cash transfer (CCT) programs such as
Oportunidades (Mexico), Bolsa Família (Brazil) and Chile Solidario that have emerged as key
elements of Latin American social policy. CCTs are programs targeted at the desperately poor in
which small cash transfers are tied to such measures as ensuring school attendance, health
checkups for children, or non-participation in child labour. Latin American CCTs are widely
cited as success stories.7 As part of a substantial increase in social expenditure in Latin America
(Sáinz, 2006), they have led to short-term improvements in health indicators (Gertler, 2004;
6 An especially striking example that post-dates the era of structural adjustment is the Bank’s
extraordinary social protection sector strategy document, which redefines the task of social policy as
social risk management starting from the premise that “In an ideal world with perfectly symmetrical
information and complete, well-functioning markets, all risk management arrangements can and should
be market-based (except for the incapacitated)” (Holzmann & Jörgensen, 2001: 16). .
7 Notably, in the case of Bolsa Família, in the Interim Statement of the Commission on Social
Determinants of Health (2007) and by the World Bank (World Bank, 2007a).
16
Lagarde, Haines & Palmer, 2007) and modest reductions in poverty and economic inequality,
albeit from historically high levels (in most countries in the region) that were exacerbated by two
decades of economic integration. However, one study warns that “substantial reductions of
inequality are not likely to be achieved without paying ample attention to employment policies
and reversing the inequality-increasing biases of social security systems,” which tend to be
predicated on long-term participation in formal labour markets (Soares, Guerreiro Osório &
Costa, 2007: 19). Another observer warns that in rural Mexico, “without attention to livelihoods,
CCTs will be educating young people principally for export – to the lower rungs of the
metropolitan labour markets” (Molyneux, 2007: 73). Hall (2006) expresses similar concerns
about Bolsa Família, with respect both to its long-term poverty reduction impact and the effects
of its competition for public funds with investments in education and infrastructure. (Here the
theme of revenue constraints as obstacles to more substantial poverty reduction efforts emerges
again.) CCTs also have ideological content, targeting as they do targeting the ‘poorest of the
poor’ in order to enhance their children’s human capital (Hall, 2006; Molyneux, 2006). This
rationale is rooted in a development policy vision that expects households to earn their way out
of poverty in the competitive labour market 8 and is thoroughly congruent with the market-based
ideal of citizenship described by Schild. Conversely, the presumption is that poor households
require “supervision” if they are to behave appropriately,9 implicitly assigning responsibility for
poverty to the poor – a core theme of neoliberal discourse in poor societies and rich alike10 –
rather than to structurally embedded inequalities.
What does the history of CCTs tell us about globalization and constraints on social
policy? Teichman’s important research on the Chilean and Mexican programs identifies linkages
forged in the era of structural adjustment between domestic policy elites and the World Bank and
Inter-American Development Bank, which have been strong promoters of CCTs, as an important
contributor to their adoption – not least by insulating the programs from challenges by domestic
civil society organizations (Teichman, 2007). More centrally to the perspective advanced here,
Teichman uses the language of “redistributive settlements” to situate CCTs in a political context
8 On the practical limitations of this prescription, as experienced in the Mexican context, see in addition
to the sources cited earlier (Parrado, 2005).
9 In the words of an unpublished Brazilian evaluation cited by Hall (2006: 25).
10 Cf. the title of the 1996 legislation that dismantled Aid to Families for Dependent Children in the
United States: The Personal Responsibility and Work Opportunity Reconciliation Act (emphases added).
17
that include not only the prospect of capital flight (at least in Chile) but also seriously weakened
labour movements; political resistance by strengthened business elites to tax-funded social
protection programs; and in Mexico fiscal constraints associated with a huge publicly financed
bailout of politically well connected bankers during the 1995 financial crisis (Teichman, 2008).
She observes that “resisters to a new redistributive settlement may include not just the business
community, but also upper and middle-income groups … along with technocratic allies within
the state” (p. 447). At best, Teichman concludes, CCTs “are able to garner a very grudging
societal consensus” that falls far short of support for “sufficiently redistributive policy outcomes”
even in the context of electoral democracy (Teichman, 2008: 456). Arguably demonstrating this
point in another country context, in December 2007 Brazil’s Senate voted against renewing the
tax on financial transactions that provided much of the funding for Bolsa Família – a loss likely
to be cushioned only temporarily by the strong revenue situation of the Brazilian government
(Alvares de Azevedo e Almeida, 2008).
5. Conclusion
I have argued that development, poverty reduction and global health agendas must be linked. I
have described how reorganization of production is leading to increased polarization in labour
market outcomes and opportunities, and how financial markets – more accurately, owners of
assets traded in those markets – “can now exercise the accountability functions associated with
citizenship: they can vote governments’ economic policies in or out, they can force governments
to take certain measures and not others” (Sassen, 2003:70; see generally Sassen, 1996).
However, I have further suggested that external influences like the operations of financial
markets may not represent the most serious constraint on national policy responses. Rather, that
constraint may arise from the difficulty of building domestic political pluralities in support of
such responses. That difficulty may, in turn, reflect changes in class structure that are influenced
by globalization, as well as the active promotion of neoliberal policy perspectives.
This position is clearly preliminary, but it suggests important lessons and warnings. We
who advocate for global value change in support of health equity must be cognizant of obstacles
to implementing that value change within national borders, even under conditions that are
relatively favourable (e.g., as in the case of the CCTs briefly discussed here, middle- rather than
18
low-income status and formal democracy). We must more actively build bridges with other
social scientists who, while not primarily concerned with health, are sources of expertise on
comparative social policy and therefore, by implication, on many of the policies that influence on
social determinants of health. Comparative inquiry, involving a diversity of countries and policy
responses, will clearly be valuable: for instance to illuminate the range of conditions in which
domestic support has been mobilized for initiatives like legislative or constitutional
entrenchment of rights to health care and subsequent implementation (Hogerzeil, 2006;
Hogerzeil, Samson, Casanovas & Rahmani-Ocora, 2006). Since multilateral responses will be
needed in order to address many of the asymmetries identified by Birdsall (conspicuously in the
area of trade policy, which I have not examined here), more research is needed on the conditions
that favour, and work against, domestic political support for such responses. As incomplete and
inadequate as the Gleneagles agenda was in addressing contemporary “global politics of unequal
development” (Payne, 2006), the momentum it generated was valuable and has dissipated; we
need to investigate why that happened at the level of domestic politics within the industrialized
world as well as elsewhere.
On a darker note: intra- and inter-country inequalities resulting from globalization may
now be sufficiently well entrenched that they have become self-reinforcing, to the point where
under most circumstances any politically plausible domestic policy responses will be rearguard
actions. They may, for instance, reduce poverty but at the price of increasing inequality or
transforming citizens’ relations with one another in ways that undermine such values as
solidarity. This is not merely an abstract concern: for instance, without a level of solidarity
sufficient to maintain support for cross-subsidization, anything approaching universal health or
social insurance coverage becomes impossible. We are now finding this out in Canada as we
contemplate the precarious future and declining coverage of our tax-funded public health
insurance programs (Evans, 2006). If my apprehensions on this point are accurate, then the
earlier invocation of São Paulo may approximate a literal image of the future, and the pattern
identified by Cornia and colleagues in which globalization undermines health may become more
striking. Are there initiatives at the international level that might make this outcome less likely,
and where can the necessary support be mobilized?
19
References
Akin, J. S., Dow, W. H., Lance, P. M., & Loh, C. P. (2005). Changes in access to health care in China,
1989-1997. Health Policy & Planning, 20, 80-89.
Akin, J. S., Dow, W. H., & Lance, P. M. (2004). Did the distribution of health insurance in China
continue to grow less equitable in the nineties? Results from a longitudinal survey. Social Science
& Medicine, 58, 293-304.
Alvares de Azevedo e Almeida, T. (2008). Brazil's Bolsa Família after the demise of the CPMF tax:
extension rather than extinction. Council on Hemispheric Affairs [On-line]. Available:
http://www.coha.org/2008/02/08/brazil%E2%80%99s-bolsa-familia-after-the-demise-of-thecpmf-
tax-extension-rather-than-extinction/
Anon. (2003, July 26). Mexico's economy: The sucking sound from the East. The Economist, 35-36.
Appelbaum, R. & Lichtenstein, N. (2007). A New World of Retail Supremacy: Supply Chains and
Workers' Chains in the Age of Wal-Mart. International Labor and Working-Class History, 70,
106-125.
Arrunada, B. & Vazquez, X. H. (2006). When your contract manufacturer becomes your competitor.
Harvard Business Review, 84, 135-144.
Asian Development Bank (2007). Asian Development Outlook 2007. Manila: Asian Development Bank.
Barff, R. & Austen, J. (1993). 'It's gotta be da shoes': Domestic manufacturing, international
subcontracting, and the production of athletic footwear. Environment and Planning A, 25, 1103-
1114.
Beja, E. L. (2006). Was Capital Fleeing Southeast Asia? Estimates from Indonesia, Malaysia, the
Philippines, and Thailand. Asia Pacific Business Review, 12, 261-283.
Birdsall, N. (2006). The World is not Flat: Inequality and Injustice in our Global Economy, WIDER
Annual Lecture. Helsinki: World Institute for Development Economics Research. Available:
http://www.wider.unu.edu/publications/annual-lectures/annual-lecture-2005.pdf.
Bronfenbrenner, K. (2000). Uneasy Terrain: The Impact of Capital Mobility on Workers, Wages, and
Union Organizing Ithaca, NY: New York State School of Industrial and Labor Relations, Cornell
University.
Brown, T. M., Cueto, M., & Fee, E. (2006). The World Health Organization and the Transition From
"International" to "Global" Public Health. American Journal of Public Health, 96, 62-72.
Caldeira, T. P. (2000). City of Walls: Crime, Segregation and Citizenship in São Paulo. Berkeley:
University of California Press.
Camdessus, M. (1995). The IMF and the Challenges of Globalization-- The Fund's Evolving Approach to
its Constant Mission: The Case of Mexico, address at Zurich Economics Society. Washington,
DC: International Monetary Fund. Available:
http://www.imf.org/external/np/sec/mds/1995/mds9517.htm
20
Cerny, P. G. (2000). Restructuring the Political Arena: Globalization and the Paradoxes of the
Competition State. In R. D.Germain (ed.), Globalization and its Critics: Perspectives from
Political Economy (pp. 117-138). Houndmills: Macmillan.
Chen, S. & Ravallion, M. (2004). How Have the World's Poorest Fared since the Early 1980s? The World
Bank Research Observer, 19, 141-169.
Commission for Africa (2005). Our Common Interest: Report of the Commission for Africa. London:
Commission for Africa.
Commission on Social Determinants of Health (2007). Achieving Health Equity: from root causes to fair
outcomes. Interim Statement. Geneva: World Health Organization. Available:
http://www.who.int/social_determinants/resources/csdh_media/csdh_interim_statement_07.pdf.
Cornia, G. A., Rosignoli, S., & Tiberti, L. (2007, December). Globalisation and health: Impact pathways
and recent evidence. Conference on Mapping Global Inequality, University of California Santa
Cruz. Available: http://repositories.cdlib.org/cgirs/mgi/mgi-7/ [other reports of this research are
in preparation].
Cox, R. W. (1999). Civil society at the turn of the millenium: prospects for an alternative world order.
Review of International Studies, 25, 3-28.
de Ferranti, D., Perry, G., Ferreira, F. H., & Walton, M. (2004). Inequality in Latin America & the
Caribbean: Breaking with History? Washington, DC: World Bank.
De Vogli, R. & Birbeck, G. L. (2005). Potential Impact of Adjustment Policies on Vulnerability of
Women and Children to HIV/AIDS in Sub-Saharan Africa. Journal of Health Population and
Nutrition, 23, 105-120.
Deacon, B., Ilva, M., Koivusalo, M., Ollila, E., & Stubbs, P. (2005). Copenhagen Social Summit ten years
on: The need for effective social policies nationally, regionally and globally (Rep. No. 6).
Helsinki: Globalism and Social Policy Programme, STAKES. Available:
http://gaspp.stakes.fi/NR/rdonlyres/4F9C6B91-94FD-4042-B781-
3DB7BB9D7496/0/policybrief6.pdf.
Dicken, P. (2007). Global Shift: Reshaping the Global Economic Map in the 21st Century (5th ed.) New
York: Guilford Press.
Donaghu, M. & Barff, R. (1990). Nike just did it: International subcontracting and flexibility in athletic
footwear production. Regional Studies, 24, 537-552.
Duménil, G. & Lévy, D. (2004). Neoliberal Income Trends: Wealth, Class and Ownership in the USA.
New Left Review, new series no. 30, 105-133.
Dummer, T. J. B. & Cook, I. G. (2007). Exploring China's rural health crisis: Processes and policy
implications. Health Policy, 83, 1-16.
Eide, A. (2005). The Importance of Economic and Social Rights in the Age of Economic Globalisation. In
W.B.Eide & U. Kracht (eds.), Food and Human Rights in Development, Volume I: Legal and
institutional dimensions and selected topics (pp. 3-40). Antwerp: Intersentia.
21
Erman, B., McNish, J., Perkins, T. & Scoffield, H. (2007, November). The black box explodes. The
Globe and Mail [Toronto].
Evans, P. (2005). Neoliberalism as a Political Opportunity: Constraint and Innovation in Contemporary
Development Strategy. In K.Gallagher (ed.), Putting Development First: The Importance of
Policy Space in the WTO and IFIs (pp. 195-215). London: Zed Books.
Evans, R. G. (2006). From World War to Class War: The Rebound of the Rich. Healthcare Policy /
Politiques de Santé, 2, 14-24.
Faiguenbaum, S., Berdegue, J. A., & Reardon, T. (2002). The Rapid Rise of Supermarkets in Chile:
Effects on Dairy, Vegetable, and Beef Chains. Development Policy Review, 20, 459-471.
Feachem, R. G. A. (2001). Globalisation is good for your health, mostly. British Medical Journal, 323,
504-506.
Ferguson, N. & Schularick, M. (2007). "Chimerica" and the Global Asset Market Boom. International
Finance, 10, 215-239.
Flynn, M. (2007). Between Subimperialism and Globalization: A Case Study in the Internationalization
of Brazilian Capital. Latin American Perspectives, 34, no. 6, 9-27.
Fudge, J. & Cossman, B. (2002). Introduction: Privatization, Law, and the Challenge to Feminism. In B.
Cossman & J. Fudge (eds.), Privatization, Law, and the Challenge to Feminism (pp. 3-40).
Toronto: University of Toronto Press.
Gereffi, G., Humphrey, J., & Sturgeon, T. (2005). The governance of global value chains. Review of
International Political Economy, 12, 78-104.
Gertler, P. (2004). Do Conditional Cash Transfers Improve Child Health? Evidence from PROGRESA's
Control Randomized Experiment. American Economic Review, 94, 336-341.
Goldfajn, I. (2003, October). The Brazilian Crisis, the Role of the IMF and Democratic Governability
[On-line]. Available:
http://www.clubmadrid.org/cmadrid/fileadmin/Brazil_paper_Goldfajn_2_revised_Oct_20_2003.
pdf. [The author was Deputy Governor for Economic Policy at the Central Bank of Brazil,
September 2000 -July 2003.]
Goodman, Peter S and Pan, Philip P (2004, February 8). Chinese Workers Pay for Wal-Mart's Low
Prices. Washington Post.
Griffith-Jones, S. & Stallings, B. (1995). New global financial trends: implications for development. In B.
Stallings (ed.), Global Change, Regional Response: The New International Context of
Development (pp. 143-173). Cambridge: Cambridge University Press.
Grossman, G. & Rossi-Hansberg, E. (2006). Trading tasks: a simple theory of offshoring. Princeton:
Princeton University [On-line]. Available: http://www.princeton.edu/~grossman/offshoring.pdf.
Gwatkin, D. R. (2005). How much would poor people gain from faster progress towards the Millennium
Development Goals for health? The Lancet, 365, 813-817.
22
Hall, A. (2006). From Fome Zero to Bolsa Família: Social Policies and Poverty Alleviation under Lula.
Journal of Latin American Studies, 38, 689-709.
Harvey, D. (2005). A Brief History of Neoliberalism. Oxford: Oxford University Press.
Harvey, D. (2006). Neo-liberalism and the restoration of class power. In Spaces of Global Capitalism (pp.
9-68). London: Verso.
Hays, C. L. (2003, July 27). The Wal-Mart Way Becomes Topic a in Business Schools. New York Times.
Health, Nutrition and Population Group, World Bank. HNP Stats [On-line]. Available:
http://go.worldbank.org/N2N84RDV00
Hearson, M. & Eagleton, D. (2007). Who Pays? How British Supermarkets are Keeping Women Workers
in Poverty. London: Action Aid International.
Heisz, A. (2007). Income Inequality and Redistribution in Canada: 1976 to 2004 (Analytical Studies
Branch Research Paper 298). Ottawa: Statistics Canada.
HiFX Foreign Exchange (2007). Daily Global Foreign Exchange turnover rises to USD 3.2 trillion [Online].
Available:
http://www.hifx.co.uk/marketwatch/market_news/headlines/uk_Daily_Global_Foreign_Exchang
e_turnover_rises_to_USD_3,-d-,2%20trillion.aspx
Hoffman, K. & Centeno, M. A. (2003). The Lopsided Continent: Inequality in Latin America. Annual
Review of Sociology, 29, 363-390.
Hogerzeil, H. V. (2006). Essential medicines and human rights: what can they learn from each other?
Bulletin of the World Health Organization, 84, 371-375.
Hogerzeil, H. V., Samson, M., Casanovas, J. V., & Rahmani-Ocora, L. (2006). Is access to essential
medicines as part of the fulfilment of the right to health enforceable through the courts? The
Lancet, 368, 305-311.
Holzmann, R. & Jörgensen, S. (2001). Social Protection Sector Strategy: From Safety Net to
Springboard. Washington, DC: World Bank.
Hopkins, S. (2006). Economic stability and health status: Evidence from East Asia before and after the
1990s economic crisis. Health Policy, 75, 347-357.
Hulme, D. (2007). The Making of the Millennium Development Goals: Human Development Meets
Results based Management in an Imperfect World (BWPI Working Paper No. 16). Manchester:
Brooks World Poverty Institute, University of Manchester.
Jenkins, R. (2004). Globalization, production, employment and poverty: debates and evidence. Journal of
International Development, 16, 1-12.
Jones, A. (1998). Re-theorising the core: a `globalized' business elite in Santiago, Chile. Political
Geography, 17, 295-318.
23
Kaplinsky, R., Morris, M., & Readman, J. (2002). The Globalization of Product Markets and
Immiserizing Growth: Lessons From the South African Furniture Industry. World Development,
30, 1159-1177.
Kawachi, I. & Wamala, S. (2007). Poverty and Inequality in a Globalizing World. In I.Kawachi & S.
Wamala (eds.), Globalisation and Health (pp. 122-137). Oxford: Oxford University Press.
Kenworthy, L. & Pontusson, J. (2005). Rising Inequality and the Politics of Redistribution in Affluent
Countries. Perspectives on Politics, 3, 449-471.
Kingdon, G. & Knight, J. (2005). Unemployment in South Africa, 1995-2003: Causes, Problems and
Policies. Oxford: Centre for the Study of African Economies, University of Oxford.
Koelble, T. & Lipuma, E. (2006). The effects of circulatory capitalism on democratization: Observations
from South Africa and Brazil. Democratization, 13, 605-631.
Krugman, P. (1995). Growing world trade: Causes and consequences. Brookings Papers on Economic
Activity, 1995, 327-377.
Labonte, R., Blouin, C., Chopra, M., Lee, K., Packer, C., Rowson, M. et al. (2007). Towards Health-
Equitable Globalization: Rights, Regulation and Redistribution, Globalization Knowledge
Network Final Report to the Commission on Social Determinants of Health. Ottawa: Institute of
Population Health, University of Ottawa. Available:
http://www.who.int/entity/social_determinants/resources/globlalization_kn_07_2007.pdf.
Labonte, R. & Schrecker, T. (2007a). Foreign policy matters: a normative view of the G8 and population
health. Bulletin of the World Health Organization, 85, 185-191.
Labonte, R. & Schrecker, T. (2007b). Globalization and social determinants of health: Introduction and
methodological background (part 1 of 3). Globalization and Health, 3. Available:
http://www.globalizationandhealth.com/content/3/1/5.
Labonte, R. & Schrecker, T. (2007c). Globalization and social determinants of health: The role of the
global marketplace (part 2 of 3). Globalization and Health, 3. Available:
http://www.globalizationandhealth.com/content/3/1/6 .
Labonte, R., Schrecker, T., & Sanders, D. (2008). Trade policy and health equity: Can they avoid a
collision? In C. Blouin, N. Drager, & J. Heymann (eds.), Trade and Health: Seeking Common
Ground ( Montréal: McGill-Queen's University Press .
Lagarde, M., Haines, A., & Palmer, N. (2007). Conditional Cash Transfers for Improving Uptake of
Health Interventions in Low- and Middle-Income Countries: A Systematic Review. Journal of
the American Medical Association (JAMA), 298, 1900-1910.
Lake, A., Whitman, C. T., Lyman, P. N., & Morrison, J. S. (2006). More than Humanitarianism: A
Strategic U.S. Approach Toward Africa (Independent Task Force Report No. 56). New York:
Council on Foreign Relations.
Levy, F. & Murnane, R. J. (2006). How computerized work and globalization shape human skill
demands. Massachusetts Institute of Technology [On-line]: Available:
http://web.mit.edu/flevy/www/computers_offshoring_and_skills.pdf
24
Loungani, P. & Mauro, P. (2002). Capital Flight From Russia. Conference on Post-Election Strategy,
Moscow, 2000. Washington, DC: International Monetary Fund.
Luke, N. (2005). Confronting the 'Sugar Daddy' Stereotype: Age and Economic Asymmetries and Risky
Sexual Behavior in Urban Kenya. International Family Planning Perspectives, 31, 6-14.
Meng, Q. (2007). Developing and implementing equity-promoting health care policies in China. Case
study prepared for the Health Systems Knowledge Network, WHO Commission on Social
Determinants of Health [unpublished].
Mishel, L., Bernstein, J., & Allegretto, S. (2007). The State of Working America 2006/07. Ithaca, NY:
Cornell University Press.
Mishra, V., Bignami, S., Greener, R., Vaessen, M., Hong, R., Ghys, P. et al. (2007). A study of the
association of HIV infection with wealth in sub-Saharan Africa (DHS Working Paper 31).
Calverton, MD: Macro International. Available: http://www.popline.org/docs/318898.
Molyneux, M. (2006). Mothers at the Service of the New Poverty Agenda: Progresa/ Oportunidades,
Mexico's Conditional Transfer Programme. Social Policy and Administration, 40, 425-449.
Molyneux, M. (2007). Two Cheers for CCTs. IDS Bulletin, 38, no. 3, 69-74.
Moser, K. A., Leon, D. A., & Gwatkin, D. R. (2005). How does progress towards the child mortality
millennium development goal affect inequalities between the poorest and least poor? Analysis of
Demographic and Health Survey data. British Medical Journal, 331, 1180-1182.
Mosley, L. (2003). Global Capital and National Governments. Cambridge: Cambridge University Press.
Mosley, L. (2006). Constraints, Opportunities, and Information: Financial Market-Government Relations
around the World. In P. Bardhan, S. Bowles, & M. Wallerstein (eds.), Globalization and
Egalitarian Redistribution (pp. 87-119). New York and Princeton: Russell Sage Foundation and
Princeton University Press.
Nadvi, K. (2004). Globalization and Poverty: How can Global Value Chain Research Inform the Policy
Debate? IDS Bulletin, 35, no. 1, 20-30.
Ndikumana, L. & Boyce, J. K. (2003). Public Debts and Private Assets: Explaining Capital Flight from
Sub-Saharan African Countries. World Development, 31, 107-130.
Neumayer, E. & De Soysa, I. (2005). Trade Openness, Foreign Direct Investment and Child Labor. World
Development, 33, 43-63.
Neumayer, E. & De Soysa, I. (2006). Globalization and the Right to Free Association and Collective
Bargaining: An Empirical Analysis. World Development, 34, 31-49.
Neumayer, E. & De Soysa, I. (2007). Globalisation, Women's Economic Rights and Forced Labour. The
World Economy, 30, 1510-1535.
Nickell, S. & Bell, B. (1995). The collapse in demand for the unskilled and unemployment across the
OECD. Oxford Review of Economic Policy, 11, 40-62.
25
Paes de Barros, R., Contreras, D., Feres, J. C., Ferreira, F. H. G., Ganuza, E., Hansen, E. et al. (2002).
Meeting the Millennium Poverty Reduction Targets in Latin America and the Caribbean.
Santiago: United Nations Economic Commission for Latin America and the Caribbean.
Paluzzi, J. E. & Farmer, P. E. (2005). The Wrong Question. Development, 48, no. 1, 12-18.
Parrado, E. A. (2005). Economic restructuring and intra-generational class mobility in Mexico. Social
Forces, 84, 733-757.
Payne, A. (2006). Blair, Brown and the Gleneagles agenda: making poverty history, or confronting the
global politics of unequal development? International Affairs, 82, 917-935.
Pogge, T. (2004). The First United Nations Millennium Development Goal: a cause for celebration?
Journal of Human Development, 5, 377-397.
Rodrik, D. (2007). How to Save Globalization from its Cheerleaders. Cambridge, MA: John F. Kennedy
School of Government, Harvard University. Available:
http://ksghome.harvard.edu/~drodrik/Saving%20globalization.pdf.
Romero, S. (2000, February 15). São Paulo Journal: Rich Brazilians Rise Above Rush-Hour Jams. New
York Times.
Ross, A. (ed.) (1997). No Sweat: Fashion, free trade, and the rights of garment workers. London: Verso.
Sachs, J. D. (2007). Beware False Tradeoffs. Foreign Affairs [On-line]. Available:
http://www.foreignaffairs.org/special/global_health/sachs.
Saez, E. (2005). Top Incomes in the United States and Canada over the Twentieth Century. Journal of the
European Economic Association, 3, 402-411.
Sáinz, P. (2006). Equity in Latin America Since the 1990s, ST/ESA/2006/DWP/22. New York: United
Nations Department of Economic and Social Affairs.
Sassen, S. (1996). Losing Control? Sovereignty in an Age of Globalization. New York: Columbia
University Press.
Sassen, S. (2002). Global Cities and Survival Circuits. In B.Ehrenreich & A. Hochschild (eds.), Global
Woman: Nannies, Maids, and Sex Workers in the Economy. (pp. 254-274). New York:
Metropolitan Books.
Sassen, S. (2003). Economic Globalization and the Redrawing of Citizenship. In J. Friedman (ed.),
Globalization, the State, and Violence (pp. 67-86). Walnut Creek,CA: AltaMira Press.
Say, L., Inoue, M., Mills, S., & Suzuki, E. (2007). Maternal Mortality in 2005: Estimates developed by
WHO, UNICEF, UNFPA, and the World Bank. Geneva: Department of Reproductive Health and
Research, World Health Organization.
Schieber, G., Fleisher, L., & Gottret, P. (2006). Getting Real on Health Financing. Finance &
Development, 43, no. 4. Available:
http://www.imf.org/external/pubs/ft/fandd/2006/12/schieber.htm.
26
Schild, V. (2007). Empowering `Consumer-Citizens` or Governing Poor Female Subjects?: The
institutionalization of `self-development` in the Chilean social policy field. Journal of Consumer
Culture, 7, 179-203.
Schoepf, B. G. (2004). AIDS in Africa: Structure, Agency, and Risk. In E. Kalipeni, S. Craddock, J. R.
Oppong, & J. Ghosh (eds.), HIV & AIDS in Africa: Beyond Epidemiology (pp. 121-132). Oxford:
Blackwell.
Schrecker, T., Labonte, R., & Sanders, D. (2007). Breaking Faith with Africa: The G8 and population
health post-Gleneagles. In A.F. Cooper, J. J. Kirton, & T. Schrecker (eds.), Governing Global
Health: Challenge, Response, Innovation (pp. 181-205). Aldershot: Ashgate.
Seifert, A. M. & Messing, K. (2006). Cleaning Up After Globalization: An Ergonomic Analysis of Work
Activity of Hotel Cleaners. Antipode, 38, 557-578.
Sepehri, A., Chernomas, R., & Akram-Lodhi, H. (2005). Penalizing patients and rewarding providers:
user charges and health care utilization in Vietnam. Health Policy & Planning, 20, 90-99.
Smith, D. J. (2000). "These Girls Today Na War-O ": Premarital Sexuality and Modern Identity in
Southeastern Nigeria. Africa Today, 47, 99-120.
Soares, S. S. D., Guerreiro Osório, R., & Costa, J. (2007). Conditional Cash Transfers in Brazil, Chile
and Mexico: Impacts upon Inequality (UNDP Poverty Centre Working Paper 35). Brasilia:
International Poverty Centre.
Stoebenau, K. (2006). From those who 'have to carry men' to those who 'look to marry men': The social
organization of women's sex work in Antanarivo, Madagascar. PhD Dissertation. Baltimore:
Johns Hopkins University School of Public Health.
Streak, J. C. (2004). The GEAR legacy: did gear fail or move South Africa forward in development?
Development Southern Africa, 21, 271-288.
Sturgeon, T. (2001). How do we define value chains and production networks. IDS Bulletin, 32, no. 3, 1-
10.
Sturgeon, T. J. (2002). Modular production networks: a new American model of industrial organization.
Industrial and Corporate Change, 11, 451-496.
Teichman, J. (2007). Multilateral Lending Institutions and Transnational Policy Networks in Mexico and
Chile. Global Governance, 13, 557-573.
Teichman, J. (2008). Redistributive Conflict and Social Policy in Latin America. World Development, 36,
446-460.
UN Millennium Project (2005). Investing in Development: A Practical Plan to Achieve the Millennium
Development Goals. London: Earthscan.
UN Millennium Project Task Force on Improving the Lives of Slum Dwellers (2005). A Home in the City.
London: Earthscan.
27
UNAIDS (2007). Towards Universal Access: Scaling up priority HIV/AIDS interventions (Progress
Report, April 2007). Geneva: World Health Organization.
UNICEF (2005). Child Poverty in Rich Countries 2005. Florence: UNICEF Innocenti Research Centre.
United Nations (2007). The Millennium Development Goals Report 2007. New York: United Nations
Department of Economic and Social Affairs.
United Nations Conference on Trade and Development (2007). Foreign Direct Investment Surged Again
in 2006. New York: UNCTAD. Available:
http://www.unctad.org/en/docs/iteiiamisc20072_en.pdf
United Nations Country Team Viet Nam (2003). Health Care Financing for Viet Nam (Discussion Paper
No.2). Ha Noi: United Nations Viet Nam.
United Nations Economic and Social Commission for Asia and the Pacific (2006). Economic and Social
Survey of Asia and the Pacific 2006. New York: United Nations.
United Nations Economic Commission for Latin America and the Caribbean (2000). Social Panorama of
Latin America 1999-2000. Santiago: ECLAC.
United Nations Economic Commission for Latin America and the Caribbean (2004). A Decade of Social
Development in Latin America, 1990-2000. Santiago: ECLAC.
US General Accounting Office (1996). Mexico's Financial Crisis: Origins, Awareness, Assistance, and
Initial Efforts to Recover, GAO/GGD-96-56. Washington, DC: US General Accounting Office.
van der Hoeven, R. & Lübker, M. (2005). Financial Openness and Employment: A Challenge for
International and National Institutions. Presented at 2006 Meeting, Global Development
Network. Geneva: International Policy Group, International Labour Office. Available:
http://ctool.gdnet.org/conf_docs/Hoeven_Paper_Lunch%20Time%20Session_ILO.pdf.
Wacquant, L. (2003). Toward a Dictatorship Over the Poor?: Notes on the Penalization of Poverty in
Brazil. Punishment & Society, 5, 197-205.
Wagstaff, A., Claeson, M.et al. (2003). The Millennium Development Goals for Health: Rising to the
Challenges. Washington, DC: World Bank.
Williamson, J. (2004). The Washington Consensus as Policy Prescription for Development, World Bank
Practitioners for Development lecture. Washington, DC: Institute for International Economics.
Available: http://www.iie.com/publications/papers/williamson0204.pdf
Wojcicki, J. M. (2002). "She Drank His Money": Survival Sex and the Problem of Violence in Taverns in
Gauteng Province, South Africa. Medical Anthropology Quarterly, 16, 267-293.
Wojcicki, J. M. & Malala, J. (2001). Condom use, power and HIV/AIDS risk:sex-workers bargain for
survival in Hillbrow/Joubert Park/Berea, Johannesburg. Social Science & Medicine, 53, 99-121.
Woodall, Pam (2006, September 16). The new titans: A survey of the world economy. Economist, 380.
28
Woodward, D. & Simms, A. (2006). Growth is Failing the Poor: The Unbalanced Distribution of the
Benefits and Costs of Global Economic Growth, ST/ESA/2006/DWP/20. New York: United
Nations Department of Economic and Social Affairs.
World Bank (1995). World Development Report 1995: Workers in an Integrating World. New York:
Oxford University Press.
World Bank (1999). World Development Report 1999/2000: Entering the 21st Century New York:
Oxford University Press.
World Bank (2007a). Bolsa Família: Changing the Lives of Millions in Brazil [On-line]. Available:
http://web.worldbank.org/WBSITE/EXTERNAL/COUNTRIES/LACEXT/BRAZILEXTN/0,,con
tentMDK:21447054~pagePK:141137~piPK:141127~theSitePK:322341,00.html
World Bank (2007b). Global Economic Prospects 2007: Managing the Next Wave of Globalization.
Washington, DC: World Bank.
Yalnizyan, A. (2007). The rich and the rest of us: the changing face of Canada's growing gap. Ottawa:
Canadian Centre for Policy Alternatives.

paper

2008-05-06T08:44:00.000-07:00

Political Mobilization of Avian Influenza: Patterns of Collaboration and Co-option under
Pandemic Frame
By Mika Aaltola
University of Minnesota
aalto007@umn.edu
Abstract
The article reviews different historically and culturally conditioned role positions available to
actors under pandemic dramas. Although it concentrates on the contemporary scene of Avian
Influenza, the aim is to examine the precursor epidemic scares such as BSE and SARS. To make
sense of the patterns of collaboration and possible co-option, paper reviews history of interaction
between international politics and epidemic diseases. This history can be better appreciated
though the concepts of legitimacy and pedagogy plays. International actors use pandemics to
further their own visions of world order. In the present case, this means that pandemics are
turned into demonstrations, theaters of proof, of the value of hegemonic order. The alarm and
panic over these short-term human and animal epidemics has often reached spectacular proportions
although the actual human health consequences have been less than dramatic. The aim is to
review specific cases to determine what situations in international politics are predisposed to the
politicization of diseases and what type of diseases are especially prone to this.
“Once again, nature has presented us with a daunting challenge:
the possibility of an influenza pandemic... Together we will confront
this emerging threat and together, as Americans, we will be
prepared to protect our families, our communities, this great nation,
and our world.”
President Bush, November 2005
In his New York Times Book review published on November 27, 2005, Matt Steinglass examines
Mike Davis’ book The Monster at our door: The Global Threat of Avian Flu. The debate that
ensues highlights the discourse dynamics of recent epidemic scares. Mike Davis’ argument is
that humanity is going to face catastrophic encounter with a pandemic influenza if it does not
stop sleepwalking. His rhetoric strategy is to alarm though powerful descriptors given to the
emerging viruses: These “monsters at our door” are “extraordinary shape-shifters” capable of
“ultrafast evolutionary adaptation”. The root causes for the coming into being of such threats are
two-fold: profit-focussed pharmaceutical industry and break-down of the leadership in world
health together with social changes in the globalizing world (e.g. third world urbanization) pose
extraordinary strain on “human solidarity”. On the other hand, environmental changes, such as
global warming, are going to cause an upheaval in the nature-humanity relationship. Stainglass
considers these often mentioned points valuable but considers the main argument rhetorical: It is
not a description it claims to be but an advocacy piece meant hype up the book and to foster particular
way of thinking about global health: “[People like Davis] are wielding apocalyptic anxiety
as a tool toward a greater end: the construction of a global system of influenza surveillance
and vaccine research and delivery to protect mankind wherever the next pandemic does, inevitably,
break out”. Pandemic-speak is closely related to earlier genre of health propaganda which
serves multiple purposes under the shadow of pandemic anxiety.
Davis’ argues for the importance of “human solidarity”, togerthermindedness. This definition of
polity reminds of classical formulations of politics as a human space for deliberation over conditions
of just and happy life. Rhetoric, as part of political deliberation, is based on the existence
and on (re)discovery of the area of together-mindedness because it allows for further persuasion.
Entralgo (1970, 177) compares this to the mission of medicine in that “the mission of rhetoric is
… not to persuade but to discover the persuasive element that there may be in each case, just as
the mission of medicine is not to cure… but to ascertain how and in what measure each patient is
curable”. My aim to examine various actors of the pandemic-scares to established they visions
of “human solidarity”. Avian Influenza scare is the focus of this paper although the approach is
more general. The role of different stake-holders needs to be mapped out vis-à-vis each other in
any comprehensive study of pandemic emergencies (Padmawati and Nichter 2008, 32). What
type of political arguments are involved in their global health rhetoric? What are the roles available
for the customary actors of international relations? What type of co-optive and collaborative
patterns have materialized during the recent Avian Flu scare?
Contemporary Pandemic Frame
Although the transmission of avian flu to humans takes place almost exclusively through domesticated
species much of the attention is focused on the disease in wild birds (Jennings and
Read 2006, 21). This highlights one of the most persistent themes of recent pandemic scares:
Humanity relation to nature. In his tellingly titled book Landscapes of Fear, geographer Yi-Fu
Tuan expresses a crucial aspect of lethal epidemic diseases when he states that “sickness forcefully
directs a people’s attention to the world’s hostility”. The association between sicknesses
and hostilities is the key point. It can be interpreted in two ways. First, epidemics direct the attention
to the hostility between nature and humanity. Read in terms of a legitimacy play, many
of the recent health scares translate into crossing-of-the-species-barrier dramas. The common
theme is that the border that should not have been violated have been crossed with the result that
nature has turn hostile to the human ways. The recent examples of the crossing of the species
barrier dramas have included HIV/AIDS. It was reported early on that the pandemic originates
from Africa where it jumped from chimpanzees to humans (e.g. Fauci, 1999). This story was
revisited in Keele et al. (2006) study that but the epicenter of the transmission to the southern
Cameroon and to the decade of 1930s. The study was done in the atmosphere charged with concern
over Avian Flue crossing the species boundary to humans. The Mad Cow disease provides
another example of the anxieties associated with the species barrier (e.g. Mahy and Brown
2000). Many diseases are connected with the pathologies of globalization. Ebola 1996 spread
in what was then Zaire was blamed to new infrastructure development in Africa and the anxiety
is caused explained by the possibility that global hub-and-spoke system of air travel can spread
the deadly disease all around the world in a matter of hours. Many (re)emerging diseases are
also associated with environmental degradation and global warming. They are seen as signs of
failures by the globalizing world community and of nature fighting back over ‘unnatural’ human
ways.
Second, the idea resonates with hostility within humanity. Namely, the multi-dimensional fractions
that run across humanity become acute when epidemics receive their communal interpretation.
Especially, the political boundaries of states and nationalities provide signifiers that provide
good resonating boards for an acute epidemic disease. Both the Mad Cow disease and
SARS offer evidence of this. Before spring 1996 BSE was considered as contained disease as it
was thought to be contained to animals and largely to Britain. The crises of 1996 turned the disease
into British disease signifying the independent minded Europe-policy and de-regularization
under Thatcher government. SARS was regarded as novel disease threat and perceived as especially
dangerous problem. Moreover, its meaning was partly synchronized with existing patterns
in world politics. The patterns of blame reflected existing political animosities: In Canada and
Taiwan news reports blamed Hong Kong, Japan blamed Taiwan, Taiwan blame China, the Chinese
press blamed people from the Guangzchou province, and the Western press blamed China.
In many places, the disease was perceived to be associated with China or to the people of ethnic
Chinese origin. It may be suggested that the images of China as secretive, closed, incompetent,
and corrupt contributed to this perception. China still is an outsider of the international community
and seen as a country with limited transparency, partial reform, uneven development.
It may be argued that pandemics are produced through patterns of collaboration between a diversity
of actors representing different relevant background themes. These themes vary with epochs.
Diseases are reflexive of the underlying form and state of the prevailing political community
and its power hierarchy. In this sense, diseases are revealing. They provide an X ray of
their embeddings (Herdt 1992, 8). It may be argued that different political environments develop
different politicised pandemics: For example, Ebola’s emergence in the bi-polar world of 1976
raised little concerns whereas its post-Cold War era re-emergence in Zaire 1996 led to worldwide
attention and scare. The BSE crisis of 1996 stemmed from the underlying anxieties felt
over the enlargement and deepening integration in the Europe and that the SARS of 2003 had a
lot to do with the growing pains of the U.S. led world order. In this respect, Susan Sontag’s
(2001) notion of epidemic diseases as always ideally comprehensible entities in they own time
can be appreciated.
Thus, diseases exist, flourish, and die in bio-political environments where they adapt to local
memories, practices, and power hierarchies. In the case of pandemics, this environment is
global. Community responses to the avian flu were commonly based on practical logic developed
based on existing stereotypes, media representations, government information campaigns,
and popular rumours (Padmawati and Nichter 2008, 31). Often the studies indicate an adaptive
wisdom that stems from the local memories of past epidemics. This cultural resource is considered
as resourceful knowledge base which can be operationalized (Zhang and Pan 2008). A lot
of value is attached to these communal coping mechanisms although they are seen as very different
from the responses of modern international community. These communal responses are
deemed to be rational and scientific. However, the qualitative difference does not change the
fact that even the responses of the international community are based on collective memories and
practices. Embedded in these practices are power hierarchies which, consequently, are reproduced
in any communal crisis such as pandemic emergency. Ungar (1998, 37) states that hot
crises “are startling, as presumed in-vulnerabilities appear to be challenged”. The air is thick of
fear and the issues involved are on everybody’s lips. What then are the relevant features of the
contemporary epoch. The macro-level power-structure if hegemonic, unipolar. As in most cases
of hegemonic world order, the major focus is on deviance. The drama of world politics is often
animated by different visions of possible decline and regression. The ways in which pandemic
scares are enabled reflect these themes.
Risk Society and Precursor Diseases
It is possible to treat the recent heath related scares in terms of Beck’s famous idea of a risk society.
According to Beck (e.g. 1999) the post-modern societies are increasingly risk aware. The
failures in risk management and in economies of risks give rise to much societal anxiety and
their fear provide stimuli for vast control and surveillance policies. However, this view can be
contrasted with the hypothesis that epidemics have always been at centre of political communities
self understanding. Lindenbaum, who provides (2001, 377)) an overview of this debate,
states that diseases can be used as indicators of the underlying communal beliefs. A serious epidemic
disease illuminates social patterns and political relations between and within various
communities. Beck’s categorical statements could be countered by historical perspective that
reveals the huge importance placed on diseases throughout human history. The contextdependent
manifestations of this important commonness have not been that dissimilar from the
recent noise made about mad cows and feverish birds. The differences are rather in degree. The
emergence of an increasingly intensive global community is matched by the re-emergence of the
communal awareness of epidemic diseases and collective rituals dealing with them. Beck’s notions
of risk may actually be read as cultural expression of what epidemics mean for the new
globalized community and what its specific variety of collective self-understanding is. These
expressions can be quite easily placed in the long cultural history of epidemic diseases and of
the political impact they cause.
To better appreciate contemporary disease imagination, review of some specific epidemics is
needed. Influenza perhaps more than any other pandemic is seen as a human influenced and
technologically induced. In the case of the Spanish Flu, the mass mobilization of armies together
with new transportation technologies provided a breeding ground for the first influenza pandemic.
In the studies of general influenza, the disease is often connected with coming into being
of the global transportation infrastructure. For example, David Patterson (1986) states that “not
until the 1889-1890 pandemic, when railroads and steamships were available to transport man
and virus, can we document a truly worldwide pandemic.” Previous influenza outbreaks were
more localized, and the global seasonal pattern were harder to discern.
As pointed out in the cases of influenza, the recent conceptual history of diseases reinforces the
link between various technologies of the global space and human diseases. The source of major
health risks are increasingly seen as stemming from specific technologies: ”In a primitive society,
the major hazards are those posed by nature. In complex modern society the acts of individuals
or corporate bodies may also involve serious hazards to other members of society” (Phillips
et al. 2000). The sense of exposure to the global space leads to increasing vulnerability. Anxieties
are treated at individual level: "... anxiety about bird flue gets translated into anxiety about
the Christmas turkey” (Corcoran and Peillon 2006). This projection is induced by the mechanization
and technologization of the everyday life (work-, domestic and public places). Peoples
dependence on technology leads to visions of dependence-related failures. This sentiment reinforces
disease related awareness and puts such phenomena as bioterrorism, drug resistance, and
pandemics stemming from the global warming to the forefront of popular imagination. Cloning,
industrial food production, medical trials, pollution, genetic engineering, and toxicity elicit conflictual
sentiments. This imagination identifies the likely source of ’the coming plague’ as originating
from hybrids between modernity (technology, industry) and nature.
The recent Avian Flu scare is an event along a long sequence of pandemic spectacles. This sequence
contains the relevant memories and modes of representation which render contemporary
events meaningful in a particular way. Out the resent pandemic scares SARS, re-emerging Tuberculosis,
and Mad Cow Disease (BSE) appear the most relevant. They also provide three different
aspects of the Avian Flue discourse: Tuberculosis provides the background frame for flulike
pandemics, SARS provides for the exceptional sense of emergency, and BSE discourse enabled
the hybrid between animals, food production, and politics.
Tuberculosis: In 1882, Robert Koch, singled out the organism, Mycobacterium tuberculosis, that
caused TB. Pattern of contagion though human contact was also described. The prevention plans
included the separation of infected people, sometimes by force. Old miasmatic ideas suggested
cures such as being exposed to fresh. Disease also influenced social habits ranging from a
frowned upon spitting to the romanization of the diseases (e.g. Sontag 2001). Early 20th century
witnessed large scale health programs against the disease that often took of the form of a “war on
Consumption”. By late 1940s, antibiotics led to an appearance that tuberculosis had been defeated.
However, as the attention decreased the programs and drug-development that highly dependent
on maintaining political commitment suffered. Recent resurgence in the United States
and other industrialized countries has taken place among certain communities and “risk groups”.
In 1993 the WHO declared TB "a global health emergency".
SARS: Severe Acute Respiratory Syndrome (SARS) was first discovered in Feb. 2003. The ensuing
SARS pandemic lasted 8 months. During the epidemic, there were about 8,000 known
cases, with 800 deaths. The death rate of SARS was estimated at 15% (90% of SARS cases occurred
in health care workers). SARS is believed to be a strain of the Corona virus, which is
linked to the common cold. Symptoms include a high temperature and a dry cough. More severe
respiratory symptoms follow within 10 days and many patients develop pneumonia. There is no
vaccine, but antibiotics and antiviral drugs have improved cases in some patients. The disease is
actually difficult to transmit and is passed by close contact with a person infected. This would
result with breathing in the droplets that are breathed in when the patient coughs. Hong Kong
announced early on that 80% of SARS cases could be tracked to a doctor in the Guangdong region
of China. China reported the disease a full four months after discovering it, by then point
305 had fallen ill and 5 had died.
In the pandemic discourse, state is often seen as an obstacle to the effective public health actions.
States are seen as secretive, non-transparent, and deceptive (e.g. Slack 1991, 119). For example,
SARS challenged China in several ways (e.g. Freedman 2004). The control of the outbreak in
such populous and rapidly urbanizing posed significant dilemmas. However, the political front
posed more noticeable and international marked problems for legitimacy management. The apparent
secrecy and denial led to a wide spread perception that China with its different political
system was the root cause behind the epidemic. Chinese government was perceived to be
opaque in its handling of the disease and was accused of excessive several times during the outbreak.
The government in China was seen as trying to cover the severity of the epidemic. For
example, on April 18, TIME magazine reported that health officials in Beijing tried to cover-up
the scale of the city's SARS infections by driving around dozens of patients in ambulances and
moving others to hotels during hospital inspection visits by WHO officials. The secrecy of any
government is seen as having many detrimental effects. It allows for the further spread of the
disease and delays the ability for the world to prepare and research possible vaccines for the illness.
Furthermore, secrecy can encourage media-fed hysteria. Many felt that the disease was
sudden and quick spreading when, in fact, it had been spreading for a full 4 months. This furthered
the sense of urgency and increased anxiety for the average citizen. It made it appear as
though one could contract the disease while walking down the street. The perceived Chinese secrecy
during the SARS outbreak prompted a large political backlash, with many countries calling
for reform in China. SARS turned into a tool of transformational diplomacy.
Blame was, thus, one of the memories of SARS. Seen as an Asian, and specifically Chinese disease,
SARS created several antagonist roles. China was blamed by governments and the WHO
became the protagonist of the story. It also showed the dangers of globalization and interconnectedness.
Chinese minorities all around the world were treated with suspicion. On the other
hand, SARS quickly became a disease caused by globalization and international travel. Unlike
diseases like HIV/AIDS, SARS was not stereotypes as a diseases of ‘immorality’, but was seen
as a disease of the globalizing world. It was a seen as a wake-up call to realize that international
travel brings us closer to each other and this, in turn, allows for the introduction of “foreign” diseases.
Mad Cow Disease: The sick, jerking, stumbling cows of Britain became to define European politics
during the spring of 1996. Before that spring bovine spongiform encephalopathy was considered
contained disease. It was contained in specific animals and largely to Britain. British
Secretary of Health’s announcement on March 20, 1996 on the finding of new CJD variant able
to cross the species boundary initiated the sudden crisis. The announcement raised the strong
possibility of a link between the new variant in humans and BSE-contaminated meat.
One way to approach the crisis and appreciate its legacy is to examine the novelty of BSE. The
origin of the sense of “madness” is indicative of the complex nature of health scares. First of all,
the association of the disease with prions, which were new type disease agents, reinforced the
mystery surrounding the disease (Yam 2001, 12). Shimkus (1998, 82) refers to the situation under
the title “Mad Cows, Strange Science”. In this way, the “madness” of BSE was often associated
with the uncertain science and with the unclear methods of testing of the disease. Secondly,
the madness was also associated with the unrestrained and “deregulated” nature of the
various actors involved. Two players receive particular attention in the literature: the food industry
and the British government. The food production industry, it was thought, wanted only to
make money and to cut costs. For example, Shaoul (1997, 182) concluded that the inner logic of
the food industry, driven by financial interests, was a public health problem. Much blame was
based on industrial food processing methods and intensive farming practices based on the maximizing
of profit instead of a respect for “natural” ways of doing things (Baker & Ridley 1996,
242; Hildebrandt et al. 2002).
An additional aspect of the formative Mad Cow experience was that the madness also signified
the panic and hysteria caused by the disease. The theme of health scare offered an additional
element for the understanding of Mad Cows. The health scare was seen as a fundamentally irrational
process that can under certain circumstances overwhelm rational behavior. For example,
Jasanoff (1997) has studied the cultural antecedents of the BSE scare. He points out the tendency
of European culture to over-react and to react irrationally in panic. Finucane (2002) emphasizes
the role of cultural perceptions of risk in connection with food-related illnesses. The
situation in Europe was one of advancing integration and enlargement of the communal boundaries.
At this political level, the context of BSE was very fluid and unstable, which may have
promoted the notion of Mad Cow disease “madness” (Aaltola 1999). The culturally charged
meanings led to nationalistic reactions and stereotypes, which were further fed by the sensationalistic
press (Giesecke 2000). Different quarantines and bans put in place by various Member
States and the Commission were seen as driven by panic and scare rather than rational decision
making.
When BSE became identified with United Kingdom and its previous policies, the European
Commission was able to look legitimate and decisive. Partly this 'success' stemmed from the
historically condition perception that states are secretive when it come to their public heath problems.
It can be argued that, for the European Commission, the substance of valorous decisions
centered on making the disease geographically and conceptually analogous with the United
Kingdom and its policies. In other words, the policies aimed at controlling BSE consisted almost
exclusively of measures imposed on and required of the United Kingdom. The containment of
the BSE crisis comprised of checking the United Kingdom as the source of the outbreak. Two
factors were usually emphasized here: majority of BSE cases occurred in Britain and the information
concerning the link between BSE and CJD was made public in the United Kingdom.
Thus, the BSE problem was localized into a British problem. The control of the disease and its
effects required clear concessions from the United Kingdom, regardless of whether these measures
would have any real effect on the causative agents. The dynamics of BSE situation profiled
national authorities as corrupt and, therefore, incapable of taking care of their own people. The
general message told a story of supranational power of the European Union’s institutions as the
last guarantor of people’s physical security and explicated national authorities as the problem.
An important legacy of Mad Cow Disease was that it reinforced one perceived illegitimate form
of pandemic collaboration. Too close marriage like relations between the government and industry
are seen deducing from the focus of the common interest. During the Mad Cow crisis, the
previous de-regulation of the food industry was deemed irresponsible. Deregulation, a lax administrative
culture, and excessively close interests of government and industry are held directly
responsible for the dangerous situation (Kleinert 1998).
Different pandemic dramas
As the mythology and history of plagues manifests when the physical diseases agents are given
cultural interpretations, some common patters emerge. They are often treated as omens, puzzles,
warnings, retributions, and teachings. They inevitably turn into signifiers of moral transgressions
with a political message about the necessity of restoring legitimate communal boundaries.
In the sense of global community, they translate into re-establishing the structure and firmness in
face of fluidity. More often that not, plague plays highlighted the existence of horizontal level
boundaries such as political borders between nations. These boundaries can be re-established
though the drama of potential or real quarantines, cordon sanitaire, and embargoes. The vertical
boundaries of hierarchical political order are more perceptual. However, in the increasingly delocalized
global community, the re-acknowledgment of the hierarchical world order is where the
emphasis is in the pandemic plays. The diseases influencing the marginal areas are easily translated
into most threatening one. The hierarchy threatened by the rising Chinese political clout
and Asian economies is re-established in the SARS and Avian Influenza plays. The threat stemming
from the 'below' is ultimately managed by Western institutions, states, and expertise.
Global health plays are dramatic. They re-stage the ‘real’ drama of human struggles and points
to the fragility of human existence. The drama associated with an acute pandemic shows itself in
communal reactions. From a historical perspective, this drama usually involves fits of what may
be called civil religious righteousness. Namely, people look for se-curing in their perceived
communal strength and traditional perceptions of communality. What comes about are outbursts
of customs, family values, nationalism, and ethnicity. The essential elements connected
with ones sense of belonging to a group are highlighted and strongly expressed. The other side
of these bursts that bring out the essential elements is that they repulse the unessential as harmful
and suspect. People are marginalized and stigmatized. In plague-ridden Europe, for example,
the normal communal responses to plague included the building of churches, giving of alms, pilgrimage,
burning of witches (mainly young women), and the killing of the Jews and other ‘foreign’
groups which were forced into the role of ‘plague spreaders’ or ‘well-prisoners’. The act of
fleeing has always been a vital part of the communal reactions to epidemics. Interpreted as a
metaphor, it sums up the common communal reaction to epidemics: People flee away from diseased
landscapes or isolate/quarantine themselves from the peoples associated with the disease.
This background illuminates one of the central roles in the pandemic plays, namely, that of the
antagonism of the humanity.
The deviant figure has a history that needs to be taken into account. At the mythic level of the
community, the slaying of the disease spreading ‘monsters’ was often performed by saintly figures
– e.g. saints, communal or ancestral spirit, and piety in general. It appears that diseases as
physical maladies were inseparable from their moral and political implications. The transgressions
standing behind outbreaks of epidemics were first and foremost of moral in nature. Because
moral transgressions translated easily into the language of violated border, epidemic disease
have had powerful political consequences between different communities and polities of
people.
Protagonists of the ‘plague plays’ are commonly conceived as problem solvers. The way in
which the myths frame diseases was that there was a riddle connected with them. Namely, disease
as a physical yet also always moral question was so framed as to require the exercise of
judgement in discovering its meaning and devising appropriate response. The coming of Christian
middle ages manifested a marked change in the way diseases were portrayed. The deviant
figure embodying the disease turned into a dragon. The monster that lurked at the edge of the
polity ready to kill its inhabitants was a hybrid creature half reptile, half bird with a foul fiery
dragon breath. The figure of dragon had a fiery hot breath. The deadliness of dragon breath was
related to then common notion that diseases were caused by bad air, or mal-air, miasma. The
struggle with the dragon – e.g. the famous hagiography of saint George slaying the dragon -lead
it to be either slain or driven back to where it came from, to caves. In the caves, there was always
damp and stagnant air. The driving of the beastly disease away (i.e. purifying the communal
atmosphere), required physical acts of courage and sacrifices. The disease-emergency called
for fearless dragon slayers. But more than anything else, the elimination of disease was connected
with moral judgement.
Plagues were and still often are taken to be manifestations of communal immorality and evil.
The sense of broken transgressed boundaries are much present in the iconography of contemporary
epidemic emergencies. Sars and Avian flu have often been treated as fevers caused by
globalizing world which contains dangerous transgression, porous boundaries, and hybridity. In
the case of Avian Flu, much anxiety stems from long distance routes of bird migration and from
the fact that industrial food production connects Western consumption of poultry with distant
poultry farms. The morality play of Avian influenza is animated by the sense of rapid global
spread, somatic connection to distant lands through food, nature turning into a threat, and localities
exposed without ability to protect themselves. It is in relation to these anxieties that Avian
influenza legitimacy plays actualize.
Legitimacy plays
Epidemics related legitimacy plays contain a strong moralist tendency. They are used to reaffirm
or reinvent the sense of civil religion and ideology (Lindenbaum 2001, 264; Rosenberg 1992,
279) and as signifiers of communal values and beliefs (e.g. Turner 1957). Legitimacy play involves
a fight by the protagonist – often presuming the guise of all humanity – against the bad
elements of perceived hostile nature. These elements are seldom the viruses, bacterias, or other
disease agents. Rather, disease and diseasing agents become easily associated with some minority
community or antagonist political entity. These two extreme types define a continuum along
which there exist a whole variety of other types: e.g. emigrants, tourists, drug-addicts, airtravelers,
truck-drivers, prostitutes, homosexuals, food production industries, greedy politicians,
and so on. These types find they ancestors in the more aged collective memories about polluters,
untouchables, plague-spreaders, and well-poisoners. The protagonists of the morality plays include
such stock figures as watchful doctors, alert health surveillance institutions, efficient national,
international and transnational health agencies, and politicians ‘who did their job’.
Legitimacy plays involve a communal verdict, a passing of a judgement about the moral status of
those involved. Legitimacy plays can be said to put the limelight on actors’ values and their ability
to make correct choices. The main question becomes how well actors choose: Do their
choices reflect progressive or regressive moral health? In connection with lethal epidemic diseases,
the underlying moral health may be interpreted either in retroactive or proactive context.
Retroactive legitimacy plays set stage for spectacles where events are at their critical stage.
From that moment onwards, there is a strong sense that events can continue either negatively/
regressively or positively/progressively. In their contemporary form, these morality plays are set
in ‘hot spots’ where epidemics are being contained by people wearing masks and protective gear.
The proactive legitimacy plays manifest themselves in spectacular acts of being on guard, sounding
alarm, and surveillance. Namely, it can be argued that one major way of doing the morally
virtuous labor in contemporary times is through sweating over the health related concerns. The
perspiration in the connection of the feverish agitation of the globalizing world provides the setting
for the staging of the epidemic related morality plays. These morality plays contain a stern
moral lesson about the disastrous consequences of laxness and lack of vigilance. In this respect,
the morality plays are not so much focused on teaching of correct behavior, the virtues and values
well functioning – i.e. healthy – global order and governance.
In the context of a legitimacy play, it is possible examine pandemic scares as moral panics. There
are various types of moral panic. A common dichotomy exists between elite induced and spontaneous
grassroots type of crises (Goode and Ben-Yehuda 1994). These crises give different
roles to different actors. For example, spontaneous crises can lead to elite reassurance of the
status-quo and of the sense of invulnerability. The opposite may also occur when the general
population is not engrossed by a sense of panic but ignores the alarmist signals coming from different
elite groups. This type of failure might indicate in-group problems within the elite. Thus,
it seems that the situation is often a mixed one: Different in-groups compete over the sense of
crisis and reflect the opinions of their respective audiences at the grass-roots level. In many
ways, the emergence of an epidemic frame indicates who is who at the elite and grass-roots level.
Besides the different participants of the spectacle, there are events that are deemed to be beyond
the control of the actors. There is the initial sense of alarm over a threat from within or without
the community. The may be a sense of natural, unnatural, or human origin of this alarm. However,
the sense of surprise is crucial for the emergence of an engrossing disease frame. This unexpectedness
can be due to temporal of conceptual nature of the initial happening. The timing of
the event may be surprising. For example, something that is already known by its nature reemerges.
this was the case of the outbreak of the bubonic plague in Surat, India 1994. The conceptually
unexpected happenings demand attention because of their novel nature. For example,
it may be suggested that HIV/AIDS re-invented the meaning of an epidemic disease in the 20th
century or BSE with its mysterious nature – e.g. prions – was salient because of its originality.
What is temporally and conceptually unexpected is dependent of the specific community and
relative of the communities self-identity. This means that community’s memory is more important
than its history when one evaluates what is surprising in sense of timing and in the sense of
nature.
When the perception of acute epidemic disease intertwines with polity’s – whether it is local, national,
regional, or global - production of security the situation becomes tense, charged, and dramatic.
The heightened sense of looming disaster thickens the air and sets the engrossing frame.
The frame has to do with what is at stake, what is taking place, and what are the past precedents?
Besides the frame, the performers become vitals in epidem ic related political dramas. Performers
are those who are expected to do something, who do something, and whose actions are
judged. Spectators of the drama are the everypersons whose health is perceived to be under
threat and who are also seen as the evaluating judged of the various performers. Often the media
becomes to represent the spectators and their judgments.
History of Political Epidemic Plays
When one considers the potential collaborative forms that epidemics can take in politics, it is
useful first to review the specific history of human reactions to epidemics that cross political
boundaries. Although much of the interplay between lethal epidemics and the realm of states’
interaction is contingent upon specific circumstances, some general, recurring, and conventional
themes and shapes can be detected:
A. Destability: Disease can strike some individual statesperson causing power vacuums, internal
squabbling, periods of indecision, and increasing uncertainty.
B. Imbalance: The uneven distribution of the burden of disease among states can cause shifts
in the prevailing balance of power.
C. Signifier: Epidemics are evidence about the bad shape of governance in some states that
can be read as a sign of weakness.
D. Propaganda: Lethal epidemic diseases can offer effective propaganda tools in eroding
perceptions about the enemy.
E. Co-option: A state can use the outbreak of some lethal infectious disease as an excuse for
politically motivated actions such as a military manoeuvre or economic sanctions.
F. Scare: Epidemics cause panic and drastic reactions that can cause economic hardship (e.g.
in the shape of market failures and loss of tourism).
From the perspective of this paper, I will bypass political plays that revolve around decisionmakers
illness (see e.g. Robins 1981, 154; L’ Etang 1970; Park 1986; and Karlen 1984).
B. Asymmetry effect of lethal epidemic diseases: The capacity of diseases to afflict some states
disproportionately constitutes an important way in which epidemics react with international relations
(Robins 1981). In general sense, it can be used to discern who is how in the world map in
terms of power. In more specific cases, asymmetry affects the outcomes of specific turns of
events. The brutal fate of Napoleon’s Grande Armée provides a case in point of the lopsided and
decisive effects of lethal epidemics. In the case of the moribund Russian expedition of 1812, the
typhus epidemic destroyed most of Napoleon’s half a million men. The task left to Russians,
largely untouched by the disease, was to complete the annihilation (Marshall-Cornwall 1967 and
Robins 1981). Similarly, the asymmetric effects of epidemics manifested themselves in the
tragic outcome of the contact between Spaniards and native Americans: “The lopsided impact of
infectious disease upon Amerindian populations therefore offered a key to understanding the ease
of the Spanish conquest of America – not only militarily, but culturally as well” (McNeill 1977,
2). The historian of the Peloponnesian war, Thucydides, who himself was inflicted by plague
gives a valuable and dramatic account of the consequences of asymmetry in the distribution of
epidemic disease (Thucydides 1990, 399, 401). Although plague was not the only factor which
brought about the eventual demise of Athens, it did deprive Athens of much of its war-waging
capability against its formidable enemy. More recent example is that of very uneven HIVbudern.
The developing countries especially in souther Africa face relative disadvantage compared
to the developed north. Thus, sharp asymmetries in the distribution of disease can result in
and have resulted in dramatic changes in the distribution of capabilities.
Moreover, the uneven distribution turns easily into disempowering stereotypes. As is evident
from the account by Thucydides, the uneven way in which the pestilence struck aroused the
imagination of many and charged the epidemic with persuasive analogies to other concepts.
Many of these ancient and biblical analogies carried through until the Middle Ages. During the
Middle Ages and the early modern period, one of the most puzzling and mysterious features of
plague that cried out for an explanation was that it struck in some places and killed most of the
people living there, while other places were completely spared. The pattern of spread attracted
culturally meaningful explanations. For example, it was very common to perceive plague as divine
retribution for sinful communal ways. In many stereotypic explanations, the irregular and
asymmetric pattern left behind by the epidemic of plague correlated with the relative righteousness
of various nations, localities, and individuals.
As the medieval system was replaced by the state system around the time of Westphalia, the nature
of epidemics as an international political phenomenon lost much of its religious charge and
became instead part of the mythology surrounding the concept of state. The ‘innate’ tendency of
states to derive legitimacy from a certain sense of physical and moral superiority in respect of
other states led to the common belief that other states or groups of states were more prone to the
horrors of epidemics. Every time that an epidemic struck somewhere else, the state’s legitimacy
as a secure, privileged, inimitable, and exemplary entity predestined and chosen for sovereignty
was reinforced. During the early 1830s, this sense of national self-confidence and pride was particularly
conspicuous in French attitudes towards the advancing cholera epidemic. Apparently
inspired by the sense of national pride, one French citizen proclaimed that cholera could not conquer
France because “in no other country of globe have civilization, industry, and commerce
achieved a higher degree of perfection and in no country but England are the rules of hygiene
more faithfully observed” (Larrey 1831, 28). In the end, the high degree of ‘civilisation’ that the
French and English attributed to themselves did not spare them from the cholera epidemic.
However, it did, for a moment, allow some French people to regard themselves as a first-class
nation at least in comparison to such “corrupted” and “disorderly” countries as India or Turkey
(Delaporte 1986, 16). As the religious explanations of pestilence were gradually complemented
and supplemented by beliefs and attitudes that had to do with administrative and scientific actions,
the underlying coupling between concepts such as decay or decline and disease-related notions
such as death, suffering, and fear, remained in place. The legitimacy and viability of a state
became dependent on its ability to avoid outbreaks of lethal epidemics, with the result that the
asymmetrical distribution of diseases - i.e., the ability to keep in check a disease that elsewhere
was rampant - was considered to selectively reinforce the legitimacy of states.
C. Decline: Public health is, thus, not only important in the eyes of one’s own citizens; it also
provides an invaluable instrument in proving political community's worth as a full and respected
entities. The vital power political dimension of public health translates into attempts to prove
one’s ability to abide by the international standards of public health. In international proclamations
concerning public health measures, states make use of such concepts as diligence, dutifulness,
and readiness. Thomas Hobbes famously justified the existence of states in terms of them
making people’s lives less short, nasty and brutish. The ability to provide external security is the
most common reading of this. States provide for people’s right to belong to certain bordered territory.
However, states have had a historical pressure to provide for their citizens also in other
sense. They have to provide economic well-being, property rights, rule-of-law, religion, and culture.
However, it can be claimed that one of the foremost ways that states can fulfil their constitutive
function is through contributing of seeming to contribute to the health of populations.
Starting from the quarantine regulations in the 14th century Italy, states have tried to stop the
spread of epidemics as a one of the fundamental elements of people’s se-curity. A rampant epidemic
disease is easily read as a state failure and the imaginary turns into one of decline and declinism.
An important constituent of a state or politic al community in general (e.g. empire) is
the ever present possibility that it may decline and even fall.
In the declinist framing of an epidemic diseases, the epidemic becomes only on symptom of
more acute and dangerous ‘political dis-ease’. In modern literature, the term state failure or failing
state can be associated with this type of frame. When the state cannot fulfil its basic modern
function of providing for the heath of its citizens, the stigma of failure can be associated with a
state or a region. This type of marginalization is in evidence when one reviews the way in which
current news concerning sub-Saharan Africa are framed. The frame and the fact that the prevalence
of HIV/AIDS is very high in these regions cannot be without consequences when it becomes
to they flows of structural power. Much labour, human security, financial investments,
and production capacity is lost when the life expectance in some states of the southern African
has fallen below 40 years. In many cases, those people whose life is ‘short, nasty, and brutish’
are from certain areas and groups inside the state. From a perspective, the state-ness is not distributed
evenly throughout the territory. When this condition cannot be kept at the margins outside
of the view of the outside world and in many cases from the national self-awareness serous
image and prestige problems may result.
In the absence of any objective measure of a state’s relative capabilities, the persuasive analogies
and connotations associated with a serious outbreak of an infectious disease can cause serious
harm to a state’s international standing. As bubonic plague hit Indian city of Surat in 1994, concern
over the international repercussions led initially to attempts to hide the problem and, once
that had become impossible, to efforts to downplay the seriousness of the outbreak. 8 The Indian
government has tried persistently to rid itself of the image that Western countries often associate
with developing countries, namely, that they are uncivilized, weak, chaotic, and second-rate
states inherently unable to take care of their own citizens. This Western view translates into India’s
lack of political and economic influence that is unfitting to the world’s most populous democracy.
What made the outbreak of bubonic plague an even more embarrassing and conspicuous
sign of incapability was the fact that the knowledge of how it spreads and how it can be
cured and eradicated has been there for a full century. In power political games, an outbreak of
this type was “a euphemism to embarrass a less developed country in the hopes of making the
more developed look better and safer” (Lin 1995, 2913). The fear that a disease can be seen as a
symbol of a state that is in ruin, with the corresponding political and economic consequences led
the Gabonese government to try and hide an outbreak of Ebola in 1996 and to confiscate samples
from international health workers (Troy 1996, 22). A further example of attempts to conceal an
epidemic disease is provided by Thailand’s efforts to conceal an outbreak of Cholera in 1997 by
calling it a case of ‘severe diarrhoea’. Such a tendency to hide diseases in an attempt to avoid
international embarrassment, which could potentially harm the state’s political and economic interests,
can be witnessed all over the world. As the British failed attempts to hide the BSE demonstrated,
states are rarely totally open about the outbreak of a potentially serious epidemic disease.
They have lot to loose in terms if respect, legitimacy, and status.
D.Propaganda: As forcefully as they impose themselves on communities, diseases have always
called for explanation. During the years of plague, the pestilence was a divine punishment for
sin and moral corruption. Not surprisingly, for a short moment when the epidemic of plague
struck, the city-states and other localities became citadels of righteousness. However, as time
passed by and as people grew more accustomed to plague and to the fact that it killed both the
righteous and the corrupt in equal numbers, regardless of their moral merits, the divine origin of
plague had to give way to more mundane explanations. The various ways in which its contemporaries
viewed plague were closely interwoven with the existing political conditions. In other
words, what was politically expedient also became a tool in controlling the societal effects of
plague. The plague-spreaders and well-poisoners become people’s enemies, and people’s enemies,
whether domestic or foreign, were easily presented as plague-spreaders and well-poisoners.
These foreign elements and states which were already viewed in negative terms were not hard to
come by in apportioning the blame.
As the state system became increasingly stabilised, the range of potential plague-spreaders expanded
accordingly to include the state’s external enemies. The effects of plague at the individual
level were intertwined with the broader societal and international considerations. The experiences
at various levels were connected together through parallel metaphoric dynamics that
mingled plague with evil and enemies instead of conceptually differentiating between them. Because
the analogy between plague and sinful life brought shame upon the proud citizens of citystates,
it was relatively easy to claim that plague originated from foreign and evil elements. This
logic was reinforced by an uncomplicated deduction, namely, it was clearly in the interests of
enemy states that the epidemic of plague would cause devastation and disorder to their rival.
What the enemy states could not accomplish through honest economic and political competition
they now achieved through the vicious act of spreading plague. Thus, it was not difficult through
governmental persuasion to convince the patriotic citizens that the misfortune in the form of disease
was not due to their own failures and practices of bad governance, but was somehow caused
by the enemy’s immorality and trickery. Thus, it may be suggested that there exists a natural
tendency to project emerging epidemic diseases into to the existing patterns of hostility. For example,
whether having to do with reality or not, the way on which both SARS and Avian Flu has
been associated with China provides some supports for this hypothesis.
The concept of epidemic thus contains well-established narrative dynamic that easily lead to the
attribution of death and destruction to foreign sources and political adversaries. This tendency
has been particularly pronounced during periods of heightened inter-state conflict. Not surprisingly,
the spread of AIDS in the early 1980s was soon adopted for politically advantageous purposes.
The Soviet authorities insisted that the AIDS virus was the outcome of an American military
experiment that had gone terribly wrong (Nelkin & Gilman 1991, 39).11 The purpose was to
point out that the United States was a vicious and underhanded super-power that should not be
trusted. Furthermore, for the Soviet Union, the AIDS epidemic offered an opportunity to point
out that it was AIDS-free: that it had no ‘degenerated’ and ‘corrupted’ homosexual elements.
However, AIDS never became a very potent propaganda weapon because it could be further attributed
to undesirable internal elements such as homosexuals, prostitutes, and drug-users. In
other words, many people in the West connected the disease with the ‘unnatural’ homosexual
population rather than with the general ‘corruptness’ of Western societies. It was effectively
used by the American neo-conservative movement in the beginning of 1980s to promote its own
message about family values and the need for religious revival in America. During the Cold
War, the lethal AIDS epidemic did make some international relations appearances not because of
its deadliness, but because of the age-old political reactivity and charge contained in lethal epidemics.
The discourse about any pandemic influenza often refers to the 1918 Spanish Flu as a benchmark
outbreak. It came from America across Atlantic before turning into a significant outbreak.
Influenza started spreading among the British forces in Spain, thus the name: “Within a few cycles
of infection, it was apparent that the disease had become more virulent, with a 10-fold increase
in the death rate amongst cases” (Nicholson, Webster, and Hay 2007, 102). This more
virulent virus spread throughout the world. The death rate become about 10 times higher than in
a generic influenza pandemic. The disease hit people in the 20-40 year age group. This made it
especially deadly among the soldier and greatly complicated the war efforts:
The co-option between the war and pandemic became clear in the health propaganda of the time
as is apparent from the poster above.
Tuberculosis can been seen as providing much of the background for the contemporary influenza
imagination. From this perspective, it is useful to view some of the health propaganda posters
from the beginning of 20th century.
The above posters from France connect the national struggle with tuberculosis with national defence.
Protective barriers of national border and human body were equated. The iconography of
epidemic diseases is militaristic. This strong tendency is still present in the contemporary language.
For example, the frantic struggle to contain SARS in 2003 was associated with wider national
security prerogatives. The U.S. documents on SARS often highlight the close connection
between naturally occurring and intentionally inflicted outbreaks of diseases. The foremost connection
is that the measures against naturally occurring outbreaks are conceptualized also as important
practice grounds for fighting bioterrorism. The combined dynamics is captured in the
term “health security”. The documents conceive “new health threats” stemming from (re)emerging
diseases and biological warfare agents”. From the U.S. perspective, the SARS related outlook
was a part of a larger vision to the world: The presidential directive, Biodefense for the 21st
Century, “provides a comprehensive framework for our nation’s biodefense. [It] builds on past
accomplishments, specifies roles and responsibilities, and integrates the programs and efforts of
various communities – national security, medical, public health, intelligence, diplomatic, agricultural
and law enforcement – into a sustained and focused national effort against biological weapons
threats”.17 The probable result of the integrated approach is that the occurrence of natural
epidemic disease heightens urgency the security concerns and re-contextualizes the epidemic in
question in quasi-security language.
E.Diseases as co-optive pretense: Diseases do not appear in the domestic and international
realms as distinct entities void of any reactivity with already existing political conceptions. In
other words, decision-makers speak about diseases in a language that is laden with analogies and
connotations that are meaningful from the perspective of state as an entity with a history, identity,
and role. Diseases linked up with the most common international relations concepts of strategy,
deception, and secrecy and, on the other hand, with the idea of enemy. By assigning the role of
plague-spreaders, well poisoners, and conspirators to some external enemy, such as to Catholics,
Protestants or other states, or to conspicuous internal groups, such as Jews, witches, and enemies
of the state, a state could both divert people’s anxiety and frustrations away from its own actions
and justify its actions against these perceived enemies. It was not extraordinary that, during the
epidemic, the hospitals set up to accommodate all the patients were full of political enemies; nor
it is extraordinary in modern times for politically unwanted elements to find themselves in quarantine
or isolation of one form or another. The manipulation and trickery have not been confined
to the abuse of internal enemy images, but they have also been extended to the level of international
interaction.
The management of epidemics can be an act put on deliberately to divert attention or to legitimize
actions that would have been otherwise unjustifiable. States’ declarations of intention are
often deceptive and misleading. Throughout the history of states’ interaction with epidemics, it
has been very difficult to distinguish between state’s genuine efforts to minimize the health implications
of epidemics and their opportunistic attempts to minimize or gain political benefits
from an outbreak. States have been well-placed to take advantage of the mystery surrounding
such diseases as plague in the seventeenth century, cholera in the nineteenth century, and the human
variant of the Creautzfeld Jocob disease, in the twentieth century. Moreover, the character
of this manipulation is entirely dependent on one’s position in international interaction. The
truth-value of different points of view is notoriously difficult to ascertain. However, mere appearances
and suspicions are enormously compelling reasons for taking conventionally appropriate
actions in international relations, which means that propaganda and prestige are of immense
importance that has to be taken into account in managing epidemics.
International relations have witnessed some attempts to use epidemics as pretense for military or
strategic gain. States have used regulations whose original purpose was to stop the spread of
epidemics by containment in order to “reap political benefit” (Delaporte 1986, 142). For instance,
the French restoration government used epidemics as an excuse to declare a cordon sanitaire
against Spain that at the time was in the middle of a revolution. The French monarchy
feared that the revolution might spread to France, and therefore an army was deployed along the
border, under the pretext of the cordon sanitaire (Bertier de Sauvigny 1966, 191). The United
States’ government considered the term blockade to be too offensive during the 1962 Cuban missile
crisis (White 1996, 142). So instead of a blockade, the Americans officially imposed a quarantine,
which carried at least some sense of international legitimacy. The long co-evolution between
states and epidemics has fixed and ritualized some compelling analogies that carry with
them a sense of legitimacy that cannot be dismissed even when abused without equally appealing
counter-arguments.
Ever since the beginning of the modern state system, it was important for a state’s viability that
its vital economic interests were taken into account when decisions were made concerning actions
against epidemics. In other words, various economic and political considerations emerged
as strong arguments for and against the use of drastic quarantine and cordon sanitaire measures.
It was not long after the introduction of quarantine measures that state authorities started to use
quarantines to advance the interests of their own trade and industry. There was a great temptation
to make favorable exemptions from the quarantine regulations. The resulting political situation
was highly complex and intricate, as the interests of the affected parties were often conflicting
and irreconcilable. The disagreements over the most effective and reasonable policies extended
beyond mere domestic considerations into international relations, which meant that miscalculations
could have potentially serious repercussions. Thus, the internationally shared
disease-related language provided ways of legitimizing otherwise politically impossible decisions
which were primarily motivated by economic and political self-interest, ruthless ambition,
and power politics.
As the BSE/CJD crisis demonstrated, the imposition of disease related restrictive regulations
against a certain state will almost certainly lead to accusations that the real motives behind these
actions are economic and political. The economic vitality of a state and, consequently, its relative
capabilities depend very much on the level of economic and political content of relevant
domestic actors. Not surprisingly then, the well-being of most vital parts of the economy, such
as agriculture, tourism, or foreign trade is a very important determinant of a state’s policies. In
many respects, the German ban on American pork products in 1880 offers a case in point of the
relative ease at which real health concerns are intertwined with economic protectionism and political
interest: “The German ban has proved the most interesting animal product ban of the era
because it was clearly argued on sanitary grounds but was consistently tinged with a very different
motive, namely, the protection of domestic livestock producers in particular and economic
nationalism in general” (Hoy & Nuget 1989, 199). The health scare was based on the discovery
that meat infected with trichinella spiralis could kill humans. Regardless of the ‘true’ motives of
the ban, it is clear that the dispute had much to do with protectionism not only because the
American side believed so but also because the ban benefited Germany’s own pork industry
(Snyder 1961, 4). The ban was lifted in 1891 after the adoption by the United States Congress of
satisfactory meat inspection laws. Although the ban on American pork and the lifting of the ban
were grounded in reasonable public health arguments, the episode as a whole clearly illustrates
how legitimate health concerns are intimately connected with the concept of national interest.
F. Market reactions: One the most common narrative paths of the recent epidemic related reactions
has been the predictable market reactions. When a mad cow or sick poultry is found, the
consumer reactions or their expectation will cause havoc in the markets. These reactions are
caused by expectation or reality of changes in consumption patterns or of establishment of trade
barriers between states. In the globalizing world, this reaction is one of the most common communal
reactions to the anxiety provoked by diseases. Recent epidemic based market reactions
have not only been contained to food production industry.
One of the formost aspects of the physical space of global fevers such as SARS and Avian Flu
has been the connectedness with the global infrastructure. Especially SARS was connected to
the backbone of global culture, the hub-and-spoke structure of the international air-travel. There
is a close relationship between air travel and microbial traffic (Ali & Keil 2006: Naylor 2003).
SARS created problems for the aviation industry because the rapid spread of the condition was
associated with intercontinental flight connections. The markets speculated that the industry
most under pressure from SARS were the airlines. The spread of foot and mouth diseases in
Britain, cause much additional costs that the airlines had to digest. The feverish pace of the
global interconnections is mostly based on the hub-and-spoke system by the topology of international
airports. It is perhaps not surprising that the industry most under pressure is the aviation
industry. Whereas the aviation industry represents the crossing of political and continental
boundaries, the food production industry brings with it the perception of crossing the nature versus
humanity divider. What ever, the underlying narratives are, the fact remains that in today’s
international political economy markets reactions provide a key way in which lethal epidemic
diseases are gauged.
In the case of the Avian Influenza, the collaborative pattern that was significant for different actors
perceived legitimacy was the one between institutions and industry. Among the most distinct
role differentiation among the pandemic-crisis actors is one between pharmaceutical traders
and public health protectors (e.g. Abbot 2005). Big pharma investment related arguments have
to fir the general humanitarian frame. Their role highlights the common interest related importance
of having strong property rights protections. Patents need to be protected and price controls
resisted. These policies, so the argument goes, will benefit also the poor because the industry
can undertake expansive drug development. The public health protectors argue for that the
common benefit has to give room for the governments to break patents so all also the poor will
be able to have an access to life saving innovations. Health is seen as a priority over the protection
of intellectual property rights. These two roles have their lobbyist and supporters. Among
the states, the intellectual property rights are promoted by the U.S. and other Western governments
whereas the public health promoters finds supporters among the developing countries such
as Brazil and South Africa.
It is important to point out that these new perception influence collaborative arrangement. For
example, when industrial accidents are perceived to be more likely and devastating, the relationship
that community groups have with industrial one is negatively influenced. The situation
leads to new patterns of conflict and coalition. Loyalties shift to reflect the underlying perceptions
of liabilities and blame. This collaborative dynamics delegitimizes close cooperation between
industry and state. Any perception of this can lead an assignment of blame for the disease,
its hiding, and failures in its control to these collaborative relationships.
The perceived illegitimacy of collaboration with industrial interests has emerged during the avian
influenza scare. Two anti-viral drugs called Tamiflu and Relenza which both have patent protection.
This means that the patent holders have the ability to limit the manufacture of their respective
drugs to their own company or contractors. At the current pace of production, it will take 10
years for Roche to adequately supply world demand for Tamiflu stockpiles. For example, the
U.S. currently has stockpiles for less than 1% of the American population while the WHO recommends
stockpiles for 40% of the population. The unequal distribution of vital medicine is
clear. Only about 30 countries are purchasing large quantities of the two drugs. This means that
the most developing countries will have no access to vaccines and antiviral drugs.
Pedagogic and proof plays
Another feature always present in politics of lethal epidemic diseases is the idea of teaching, political
pedagogy. Health education is pervasive characteristic in most if not in all of human societies.
Didactic plays are rooted in this deep cultural resource. The didactic plays refers to
spectacles that starts by dialectical definition which is then amplified and dramatized by narrative
and rhetoric in order to teach effectively to the just uninitiated to the global health issues as
well as advise those with more experience. Namely, pandemic related didactic drama comes in
two forms: Introductory didactic plays and advanced didactic plays. Didactic aspect subordinates
the unfolding spectacle to the exigencies of the pedagogic purpose of the political variant
of a pandemic. This characteristic varies from direct ‘preaching’ of the facts of by now politicized
pandemics to refraining from explicit moralizing and trusting the reader to draw its own
lessons from the outcome of the story. The work teaches the facts and figures but also advanced
moral attitude (prudence). Information is directed to the less initiated and the more nuanced
deeper story to those more deeply immersed. These two levels are subordinated in that the teaching
of the fact and figures in based on a framework that also teaches right consciousness and attitude
towards the globalizing world.
The frame actualizes in pandemic performances. Latour's (1988) idea of 'theater of proof' can
offer a history of medicine related way of looking into these performances where different actors
take their own roles and form collaborative relationships. The idea draws from the famous experiment
in 1882 though which Pasteur revealed the effectiveness of vaccination. The experiment
lasted for several days and was the focus of intensive attention by the French media.
Twenty-five sheep were vaccinated against anthrax. Other twenty five who were not were
painted with red markings. The success of the demonstration was highly visible for the onlookers
who witness the death of all the animals who were not vaccinated. The fame of this experiment
was enormous. It offered a clear-cut common-sensical revelatory knowledge into the
power of new health science. Pasteur managed to make the underlying difficult to comprehend
the hidden reality visible. These types of experiments were repeated around the world. At the
level of popular imagination, these laboratory experiments transferred into the field turned into
modernity's testing grounds, into theaters of proof. At the stake was the legitimacy of modern
medicine and the state that had produced it.
What qualities are inherent in the pandemic theater of proof? Latour's idea is that scientistic
theater of proof is powerful because of its seeming objective clarity. In this sense, Latour’s theater
of proof refers to “a physical space where the objects of science are said to be freed from rhetorical
distortions, faulty vision, and the inadequacies of the ‘lesser’ senses” (Crawford 1996,
67). In the same way, the universalizing ethos of the pandemic spectacle contains a tendency to
see it not as a social setting. Humanity vis a vis inhumanity turns into a direct confrontation with
the nature. In this setting, representative of health is a figure that observes directly the external
reality. This position is provided to it by the ‘true’ and ‘authentic’ foundations of the Western
civilization. The staging of the theater of proof is meant to produce an acknowledgement that
there is a technology of life which has precise
nature, definitions, and protocols.
Pandemic scare becomes a moment that renders transparent the underlying truths concerning
who promotes heath and who does not. For example, images of SARS in 2003 provided drama
that demonstrated the goodness of organizations such as WHO and hold China as suspect when it
come to its trustworthiness in increasingly inter-connected world. This legitimacy pattern became
reveal with single gaze at the media representations of SARS spreading in Hong Kong.
Theater of proof conveys power and ideology in the seemingly non-political acknowledgement
of the evident.
The pedagogic play makes it evident that what is done in the name of disease control and eradication
is beyond doubt. It benefits whole humanity. Pandemics turn into governance exercises
that are thought to be be beyond politics, at least negative politics.
Modern health propaganda has highlighted the general human interest as its main motivating factors.
Because of this apparent humanity, the political agenda of health policies often go uncognized.
However, even a cursory look into the Avian Flue debates reveals that different actors
have their own at least partly incompatible goals. For example, the sharing of epidemiological
data and samples with the WHO seems on the surface of it the self-evident right thing to do. It
accords to the common wisdom that such sharing benefits the whole of humanity, human polity.
WHO has had a 50 year old system for sharing influenza virus samples. Countries donate sample
to WHO so that manufacturers relying on the data can maintain the effectiveness of the vaccines.
This system had to be renegotiated in early 2007 when Indonesia refused to send samples
to WHO. Indonesian concerns was that it did not stand to gain from the system and that the real
beneficiaries were the Western governments in terms of vaccine supplies and pharmaceutical
companies in terms of profits. The vaccines developed from the samples were too expensive for
the developing countries when Western countries were emptying the markets. Another important
reason for the Indonesian decision was its willingness to negotiate with specific drug companies.
Indonesia wanted to give samples directly to a specific pharmaceutical company by passing
WHO system. This arrangement would have guaranteed Indonesia more direct benefits in terms
of supplies and shared profits. At the end, the crisis was resolved by granting Indonesia ‘final
say’ when it came to the commercialization of drugs developed based on Indonesian data.
The controversy over sharing data illuminates the politics of health: alternative visions, different
agendas, co-optive purposes, and clashing interests. It differentiates among actors and defines
the way in which they collaborate. Even the modern expert-driven functionalist health governance
recognizes some legitimate forms for politics. Positive politics is often seen as setting the
institutional framework for the expertise (Siddiqi ). Institutions and programs have to be established
and allocated resources. Second, public health involves more mundane yet equally necessary
role for politics. Namely, one has to choose the personnel to work in the functional field,
allocate money for the building of offices and laboratories, finance large-scale inspection programs,
and so on. As long as the justifications and reasons are based on common interest, this
role of politics is not seen as harmful even when it results in disagreements as long as they do not
result in the paralysis of expertise. Perceived harmless disagreement includes for example ‘competition’
of states over the right to host health institutions. Third, there is also the politics of expert
debates over the most effective policies. Experts can argue over the best course of action in
maintaining public health. Scientific debates, disagreements, and compromises in the field of
expertise are not seen in themselves as political in the negative sense of the word.
When reading public health literature, it soon becomes apparent that the line between positive
politics and negative politicization is crossed when politics does not enable functional field but
co-opts it for some other purposes. General opinion seems to be that such co-option leads to less
affective health policies and that it reflects badly on the perceived legitimacy of global health
policies. However, it should be noted that careful co-option relies on at least seemingly effective
and legitimate global health. Namely, this type of co-option leads to a ‘partnership’-type of collaboration
between those professing to the modern global health perspective and those with other
agendas. This partnership tends to reaffirm and re-establish the underlying rhetorical persuasiveness
of public health perspective while serving additional goals. Besides this, it is possible
to conceive two other forms of collaboration. Co-option may be based on hierarchical situation
where global health is directly subordinated to some other goals, such as strong vision of national
security. Health becomes defined as a one front in a wider struggle for a preferred goal. For example,
the U.S. HIV/AIDS related PEPFAR programs – part of ‘transformational diplomacy’ -
explicitly aim at preventing state-failures and spread of terrorism through effective health programs.
Third possible collaborative arrangement involves actors who purposefully resign from
the modern public health paradigm. For example, Indonesian refusal to share samples might
been seen a direct challenge to the expert-based health governance. Alternative co-optive form
of collaboration is the apparent lack of transparency of some actors. China was accused of this
during the 2003 SARS and later Avian Flu scares. This perceived co-option leads often to negative
prestige and lowering of international status. These co-optive roles can be named as supportive,
transformative, radical, and deviant
An example of the apparent supportive co-option is the recent regime-development stemming the
Avian Flu. Important recent development has been the formation of International Partnership on
Avian and pandemic Influenza. According to the U.S. Department of State, the partnership aims
to elevate the avian influenza issue on national agendas, coordinate efforts among donor and affected
nations, mobilize and leverage resources, increase transparency in disease reporting and
the quality of surveillance; and build local capacity to identify, contain and respond to an influenza
pandemic. On the U.S. side the partnership participation is coordinated by the Department
of State. Department of state established in March 2006 the Avian Influenza Action Group. This
group is collaborated by the Departments of Health and Human Services, Agriculture, Homeland
Security, Defense, and the U.S. Agency for International Development and other agencies. The
process lea to an unbinding declaration (“global partnership initiative”). Among other things this
text states that “[…] enhanced global cooperation on avian and pandemic influenza will provide
a template for global cooperation to address other types of health emergencies. The transformational
aspect is hidden behind global governance of public health language.
The coming-plague narratives provide a crucial element of the imagined scene for the pandemic
performances. There exists a growing strand of literature that reinforces the idea that several historical
turning points have come about when a serious epidemic disease has inflicted a population
(e.g. McNeil, Diamond). The impact of lethal epidemic diseases is described in terms of
catastrophic blows against populations that exist in confined geographical space – e.g. the collapse
of Maya-culture or the ability of Spaniards to conquer the Americas. Epidemics manifest
themselves in geographical confines by affecting mortality, population density and distribution,
and behavioral patterns. In this general line of research, it is fairly common to examine how often
uncognized human behavioral patterns – e.g. the relationship between humans and domestic
animals - affected the emergence, spread, and distribution of diseases (Diamond). The metaphor
of ‘population’ has in recent research been complemented by the concept of civilization. Especially
in the research dealing the first contact between the Europe and Amerindia civilizations,
there is tendency to treat the impact in terms of disease exchange between civilizations. The hypothesis
about syphilis and smallpox as the vital factor in the civilizational contact are rampant.
Although these interesting theorems are somewhat misplaced. they matter. Much of this influential
interdisciplinary discourse uses population and civilization based ideas of human behavior.
This discourse can be further illuminated by contrasting it with other notions of politics. For
example, a wider look into political theory should reveal that the human behavioral cohesion is
not due only to geographical barrier but mainly to the existence of multidimensional political
boundaries. This basic realization is often bypassed by the slogan that ‘political borders are porous
to diseases’.
In this respect, there seem to be a ‘human animal’ metaphor inherent in the popular concept of a
population. Apparent by-passing of the Aristotelian notion of humans as political animals living
in polities instead of populations is itself a political practice. It refers to the desire to treat epidemics
as apolitical threats. The terms chosen at meant to do work. They make politics disappear.
Politics is made cease at the populational or civilizational levels. Population metaphor
contains a sense of individuals whereas the modern civilization is used to evoke a sense of widest
possible human polity, humanity. This dual movement finds its most natural home in the contemporary
humanitarian thought.
At the level of metaphoric political bodies, sufferer is imagined in terms of an individual or humanity.
Individual as the body-in-pain is the topos of modern humanitarian compassion. The
individualization of sufferer points to an important watershed in the history of suffererconstruction.
The modern sufferer is often a contextless figure existing in the heavily temporalized
situation of health emergency. The figure represents all humanity through being human at
the mercy of outside elements of inhumanity – i.e. birds spreading Avian Flu or cows turning into
Mad Cow polluted hamburgers. This ‘zooming-in’ to the individual level allows for the construction
of the epicenter of suffering where voiceless sufferer communicates only through the
visual language of hospital patients or health-care workers with protective gear.. The complexity
– e.g. the historicity of various groups of people, they self-understanding, and the variance of
importance placed on collective suffering – recedes to the background and the patient as an expression
of humanity pain crops up. The distant sufferer in some far-way location, with distinct
and shared memories, beliefs, and myths about what has happened, why, and for what end, is
cleansed when the figure is refined into Westernized form, into generic representation of what,
how, and where might go wrong (e.g. Malkki 1996, 380). For a distant sufferer to become a
member of the general human polity, it has to be denied the membership of other seemingly narrower
political communities.
The perceived apolitical conditions inherent in the humanitarian imagery of ‘human polity’ are
comparable to those produced by related notion of developmentalism (Ferguson 1990). The term
‘anti-politics machine’ refers to the “development industries” application of technical solutions to
such political problems as conflict, poverty, suffering, and hunger. The machine – i.e. developmentalist
discourse, repertoire of established ‘solutions’, and the infrastructures/networks of actors
involved – renders the politics of distant others into a series of rational/technical problemsolving
exercises. Although this production of subjects is itself a political act, it is political in a
specific sense of the word: It is politically privileged by its appearance of being apolitical. The
humanitarianist ‘anti-politics machine’ can be shed some further light through Ronald Barthes’
(1980) concept of ‘depoliticized speech’. The practice of depoliticized speech is based on mythologizing
the political out of actions and turning them into something self-evident, required,
and essential. The sufferer becomes produced as an ahistorical and universal humanitarian subject
in the apolitical governance-language of the international agencies (Malkki 1996, 378).
However, such speech only hides the deep power-political significance of this way of constructing
the body-in-pain. The rendering of humanitarianism a realm where ethics not politics matters
enables specific types of humanitarian action and its co-option by actors in whose interest it is to
turn distant place into apolitical object of Western intervention (e.g. Minh Ha 2004, 269).
The apolitization of governance action in epidemic emergencies is among the most important
places to look for the ways in which politics and power hierarchies matter. All the actors talk in
behalf of the humanity. The failure and success in this process is relative. Some actors politicize
better than others. This circulation of legitimacy provides the stage for the political performances
of pandemic emergencies. To answer these questions, it may be suggested that diseases
manifest themselves in engaging and engrossing public plays of legitimacy and of experimentation
with various instruments of international legitimacy.
Avian Flu becomes apoliticized in particular way through the legitimacy, pedagogic and proof
plays. Firstly, the scare becomes localized. Diseases are identified with a particular area and,
often, with particular people - racialized, gendered, sexualized, and ethnicized. In both the Avian
Flu and SARS, the people who diseases were considered alarming were found in Asia. These
people are on the foreground of Western media because of outsourcing and fast economic
growth. Both print and TV media used repetitious images such as Asian citizens in masks and
animals in Southern Chinese “wet markets”. Another important aspect of pandemics is they tendency
to temporalize the situation. Time becomes increasingly salient. There is a rush to find a
cure or solution, to track and isolate the carriers. The tempo of globalizing world can easily find
its correspondence in the disease imagery. It is often the case that conclusive scientific proof
cannot be achieved without time-consuming research. This situation often leads to immediate
actions based on the worst case scenario. Often the worst case imagery blends with stereotypic
and popular beliefs.
Avian influenza scare has made the governments worldwide have spent billions planning for a
potential influenza pandemic: buying medicines, running disaster drills, and developing strategies
for tighter border controls. These actions are seemingly apolitical because they take place
inside the humanitarian frame. They are perceived as necessary and unavoidable. The policies
that are prepared to fight possible human pandemic concentrate of the different isolation procedures.
Isolation is aimed separating individuals with the infectious illness in their homes, in
hospitals, or in designated facilities. The quarantines bring about the separation and restriction
of the movement, i.e. of a group of people, who, while not yet ill, have potentially been exposed
to an infectious agent. The isolation plans often referred to different forms of social distancing,
e.g. within the workplace, social distancing measures could take the form of placing moratoriums
on hand-shaking, substituting teleconferences for face-to-face meetings, staggering breaks,
posting infection control guidelines). It is clear that there would be closing of places of assembly
such as churches, schools, and theaters. At the level of national and international borders the
plans included drastic modifications in movement patterns: Restricting movement at the border,
instituting reductions in the transportation sector, and applying cordon sanitaire procedures.
The ‘apolitical machine’ of avian flu works through two major programs. At international level,
avian influenza has led to two cooperative initiatives:
1. U.S. initiated International Partnership on Avian and Pandemic Influenza
2. Global Preparedness Plan of WHO
The American initiated Partnership is meant to improve international surveillance, transparency,
timeliness, and response capabilities. President Bush, UN General Assembly, September 2005:
“As we strengthen our commitment to fighting malaria and AIDS, we must also remain on the
offensive against new threats to public health such as the avian influenza. If left unchallenged,
this virus could become the first pandemic of the 21st century. We must not allow that to happen.
Today I am announcing a new International Partnership on Avian and Pandemic Influenza.
The Partnership requires countries that face an outbreak to immediately share information and
provide samples to the World Health Organization. By requiring transparency, we can respond
more rapidly to dangerous outbreaks and stop them on time.” Partnership's apparent emphasis is
on transparency. Transparency means international access and wide collaboration with the international
community. It requires countries facing an outbreak to immediately share information
and provide samples to the WHO. WHO plan assists WHO Member States and those responsible
for public health, medical, and emergency preparedness to respond to pandemic influenza-related
threats. It is meant assess risks and come up with preparedness plans that can then be recommended
to Member States.
Conclusion
It can be argued that global political space is in flux, constantly shifting and changing. The primary
concern is over the consequences of previous national, ethnic, and religious boundaries being
rapidly transgressed. The conventional borders that have been the foundation of world-view,
trust, and loyalty are becoming porous and weak. New process such as global warming and war
against terror are capturing imagination. The declinist sentiments anxieties and concerns over
the nature, purpose and consequences of events provide much of the dynamics for prevailing
pandemic frame. It is in this frame that pandemics like Avian Flu actualizes as a global concern
that embodies much of the myriad of the background anxieties. Beside anxieties, the episodic
pandemic dramas provide a staging ground for demonstrations of legitimacy, effectiveness, and
power. The episodes turn it highly readable plays that transform and can be used to influence the
background frame. These captivating plays are used as a momentary criterion or standard with
which the morality and legitimacy of various political actors. Failures translate into a deficiency
in fulfilling perceived obligations that are essential for membership and the consequent rights of
the increasingly global community.
Avian Flu is read as a reminder of world's networked nature. The apparent necessity to secure
the global network is judged to demand increased coordination and harmonization or preparedness,
prevention, response and containment activities. The ability of potential Avian Influenza
outbreak to close down schools, hospitals and other public spaces and, in general, to disrupt societal
organization was one of its most notable popular images. It was perceived as global danger
that manifested itself at local level. This connection nececiated global reposibility on the local
level handling of the disease threat. The speard of the disease from one localtion to another
triggered the 'global' and animated or enable manifold of global actors, such as the hero of the
story WHO. In away, the disease came with a message that demanded re-organization. It demanded
re-imagining social organization and gave opporturnities for now actors to emerge and
also required flexibility from the existing networks. The disease questioned multiple and heterogenous
connections that had existed by becoming a hyperbolized public spectacle.
References (incomplete)
Abbot, F. M. (2005). The WTO Medicines Decision: World Pharmaceutical Trade and the Protection
of Public Health. The American Journal of International Law. 99, 2: 317-358.
Beck, U. (1999). World Risk Society. Cambridge: Blackwell.
Crawford, T. H. (1996). Imaging the Human Body: Quasi Objects, Quasi Texts, and the Theater
of Proof. /PMLA/. 11, 1: 66-79.
Fauci (1999). ?. N Engl J Med.
Freedman, Amy (2004). The SARS Crisis and Challenges to regimes legitimacy in China. Conference
papers – New England Political Science Association.
Goode, E. and Ben-Yehuda, N. (1994). Moral Panics: The Social Construction of Deviance:
Cambridge: Blackwell.
Herdt, Gilbert (1992). Gay Culture in America. Boston: Beacon Press.
Jennings, Roy and Read, Robert (2006). From Influenza: Human and Avian in Practice. London:
Royal Society of Medicine.
Keele et al. (2006). Chimpanzee Reservoirs of Pandemic and Nonpandemic HIV-1. Science.
May 25th.
Latour, Bruno (1988). The Pasteurization of France. Cambridge: Harvard University Press.
Lindenbaum, Shirley (2001). Kuru, Prions, and Human Affairs: Thinking about epidemics. Annual
Review of Anthropology. 30: 363-385.
Mahy, B. W. J. and Brown, C. C. (2000). Emerging zoonoses: crossing the species barrier.
Revue-Scientifique-Et-Technique-De-L-Office-International-Des- Epizooties. 19, 1, Apr: 33-40.
Padmawati, Siwi and Nichter, Mark (2008). Community response to avian flu in Central Java,
Indonesia. Anthropology & Medicine. 15, 1: 31-51.
Patterson, D. K. (1986). Pandemic Influenza, 1700-1900: A Study in Historical Epidemiology.
London: Rowman & Littlefield Publishers, Inc.
Shimkus, J. (1998). Infection control. Mad cows and weird science. Hosp-Health-Netw. 72, 11:
62.
Sontag, Susan (1988). AIDS and Its Metaphors . New York: Farrar, Strauss and Giroux.
Rosenberg, C (1992). Explaining Epidemics and Other Studies in the History of Medicine.
Cambridge: Cambridge University Press.
Turner, V. (1957). Schism and Continuity in an African Society. Manchester: Manchester University
Press.
Ungar, Sheldon (1998). Hot Crises and Media Reassurance: A Comparison of Emerging Diseases
and Ebola Zaire. British Journal of Sociology. 49, 1: 36-56.
Weiss, Meira (1997). Signifying the Pandemics: Metaphors of AIDS, Cancer, and Heart Disease.
Medican Anthropology Quarterly. 11. 4: 456-476.
Zhang, Letian and Pan, Tianshu (2008). Surviving the crisis: Adaptive wisdom, coping mechanisms
and local responses to avian influenza threats in Haining, China. Anthropology & Medicine.
15, 1: 19-30.

paper

2008-05-06T08:43:00.000-07:00

Health Diplomacy as Soft Power:
The PRC and Africa
Jeremy Youde
Assistant Professor of Political Science
Grinnell College
Grinnell, IA 50112
youdejer@grinnell.edu
641 269 4898 (phone)
641 269 4985 (fax)
Paper prepared for the International Studies Association Conference, 27-30 March
2008, San Francisco, CA
Draft versions; comments welcome, but please do not cite without author’s permission
How does health fit into a country’s diplomatic strategies? In recent years, we have seen
moves by various states to move away from supporting health care infrastructure in
developing countries as part of its foreign aid expenditures or as a quid pro quo for
natural resources. Instead, health appears to be coming into its own as a tool of
international diplomacy. Supporting health care in developing countries is becoming
another element of developed countries deploying their ‘soft power’ to help them achieve
their international diplomatic objectives. This represents a significant change in how
governments conceptualize health and its place in the diplomatic arsenal. Health is
moving from being auxiliary or an afterthought to a more central (though certainly not
the central) location.
This shift toward emphasizing health diplomacy is perhaps most striking when we
evaluate the burgeoning relationship between the People’s Republic of China and Africa.
China’s support for African health care systems has ebbed and flowed over the past 50
years, but it is currently on an upswing. While some may be inclined to dismiss Chinese
involvement as a cynical ploy to get access to the continent’s natural resources, the
evidence simply does not bear this contention out. Instead, supporting the health care
infrastructure in various African countries is an element of China’s efforts to deploy its
soft power and receive recognition as a good citizen within the international community.
To make my argument, I will first briefly discuss the concepts of soft power and health
diplomacy, demonstrating how the two are related to each other. I will then discuss the
history of Chinese health diplomacy in Africa before turning attention to its current
manifestation. The next section will discuss how these efforts fit into China’s larger
diplomatic strategies. Finally, I will discuss potential limitations of health diplomacy as a
strategy—both in the specific case of China in Africa and more generally.
I. Soft power and health diplomacy
With the end of the Cold War, scholars re-examined the notion of power and its use
within the international arena. If power is the ability to have control over others and
compel them to do things they would not otherwise do, how does one state hold such
sway over other states in a unipolar era? Joseph Nye answered this question in 1990 by
introducing the concept of ‘soft power.’ In this new ear, Nye explained, the traditional
measures of power, such as military strength, geographic presence, and population size,
no longer held the same level of effectiveness. The world had changed in such a way that
it was often prohibitively expensive for a country like the United States to use these
sources of power to compel other states to accede to its wishes1. Instead, a country’s
technological prowess, economic growth, and educational achievement mattered more2.
Through the attractiveness of its culture, political ideology, and foreign policy, a state
could employ soft power to “get other countries to want what it wants”3. Soft power is
thus
the ability to get what you want through attraction rather than coercion or
1 Joseph S. Nye, Jr. “Soft power,” Foreign Policy 80 (Autumn 1990), 159-160.
2 Ibid., 154.
3 Ibid., 166; emphasis in the original.
payment. When you can get others to want what you want, you do not
have to spend as much on sticks and carrots to move them in your
direction…Soft power arises from the attractiveness of a country’s culture,
political ideas, and policies4.
Nye delineates three sources of a country’s soft power: “its culture (in places where it is
attractive to others), its political values (when it lives up to them at home and abroad),
and its foreign policies (when they are seen as legitimate and having moral authority)”5.
This means that soft power is more than just culture; it encompasses many different
aspects of a state’s identity and actions—aspects which are not necessarily always under
the control of the same individuals (or anyone’s explicit control, for that matter).
This does not negate the importance and relevance of traditional power measures.
Instead, soft power recognizes the limits on hard power’s effectiveness. No country can
afford (in either a diplomatic or an economic sense) could rely solely on its military
might to achieve its foreign policy agenda. More importantly, though, it encourages
others to buy into the first state’s ideas. Country B does not go along with Country A
because it feels like it must; it does so because it wants to because it respects Country A.
Self-interest certainly plays a role in facilitating cooperation, but attractiveness can be
4 Joseph S. Nye, Jr., “Soft power and American foreign policy,” Political Science
Quarterly 119 (2004), 256.
5 Joseph S. Nye, Jr. “Think again: soft power,” Yale Global Online,
, accessed 8 January 2008.
even more important6. I am more likely to make accommodations for someone whom I
respect and admire as opposed to someone who simply tries to shove his or her ideas
down my throat. International relations often work in a similar manner.
While related, soft power and popularity are not identical. Popularity is more short-term
and often responds to discrete events. Soft power, on the other hand, concerns longerterm
assessments made by other countries. Country A may adopt a particular policy
unpopular with Country B, but that is unlikely to ruin the relationship between the two if
Country A’s overall attractiveness and respect remains intact. However, if a country pays
too little attention to developing its soft power capabilities or lacks an overall strategy,
this can lead to a deterioration of its soft power7. Soft power goes beyond popularity
because it affects a country’s willingness to make concessions. Popularity addresses how
much others like or dislike a particular country, but it does not necessarily require
sacrifices or policy changes. Soft power seeks to get states to change their policies and
embrace a new worldview. This is far more extensive than popularity.
How do we know when soft power is operating effectively? Huang and Ding offer a fourstep
process model to trace soft power’s use. Soft power is effective if Country A directs
its soft power resources (1) toward the policy actors in Country B (2), which in turn
changes the policy process in Country B (3) such that they accord with Country A’s
6 Nye, “Soft power and American foreign policy,” 257.
7 Joshua Kurlantzick, “The decline of American soft power,” Current History 686 (2005),
421.
desired outcomes (4)8. This model not only provides causal linkages, but it also shows
that soft power does not always allow a country to achieve its policy preferences.
We can see evidence of soft power’s effects throughout the international arena. Recently
released Soviet documents reveal that the Cold War’s end came in large part due to
Reagan’s late embrace of soft power. When he adopted a more hawkish position, Soviet
reformers like Gorbachev found their efforts stymied by hardliners within the
government. As Reagan later positioned himself as a peacemaker and advocate of
disarmament, relations between the two countries thawed to a point that economic and
political reform in the Soviet Union could happen9. These reforms, in the long run, led to
the Soviet Union’s demise. Reagan’s more peaceful posture made the United States a
more attractive country and less of a threat, thus facilitating better relations between the
two superpowers. More recently, recent American policy decisions have significantly
harmed the United States’ soft power. By taking unilateral action and publicly disdaining
international consensus over the war in Iraq, numerous surveys have shown that the
United States’ standing in the world has taken a severe hit10. Its foreign policies are
perceived as illegitimate and without moral authority, it is widely perceived as not living
up to its professed political values, and symbols of its culture have been targets of
vandalism and violence. A 2007 survey by the Pew Global Attitude Project finds that,
between 2002 and 2007, attitudes toward the United States declined in 26 out of 33
8 Yanzhong Huang and Sheng Ding, “Dragon’s underbelly: an analysis of China’s soft
power,” East Asia 23:4 (2006), 25.
9 Vladislav M. Zubok, “Soft power,” New Republic (21 June 2004), 11.
10 Kurlantzick, 421-422.
countries11. This has had a detrimental effect on the country’s ability to see its desired
foreign policies enacted.
Huang and Ding see China as taking more steps to bolster its soft power by joining
international organizations and portraying itself as a responsible member of the
international community. PRC’s 1997 “new security concept” emphasized mutual trust
and benefit in international relations, equality, and coordination. This strategy
emphasized how China accepted a variety of shared norms within the international
community to bolster its standing with developing countries around the world12. Hill sees
Russia’s increasing stature among former Soviet republics as coming from its embrace of
soft power. Instead of trying achieve cooperation with its neighbors solely through saberrattling,
the Russian government has increasingly turned toward promoting its popular
culture, encouraging people to learn and use Russian, and utilizing its newly-found oil
and gas wealth to make itself more attractive13. In both of these cases, the government’s
embrace of soft power is still somewhat tentative. That makes any assessment of the
long-term effect limited at this point, but we can already see evidence that countries
recognize the usefulness of soft power.
Health diplomacy is simultaneously a historical reality and a recent diplomatic
innovation. This paradoxical position comes from the evolving definition of health
11 Pew Global Attitudes Project, “Global unease with major world powers,”
, accessed 8 January 2008.
12 Huang and Ding, “Dragon’s underbelly,” 29.
13 Fiona Hill, “Moscow discovers soft power,” Current History 693 (2006), 341-342.
diplomacy and changes in how the international community has responded to health
concerns. Historically, health diplomacy focused on international collaboration to protect
human and commercial interests against the spread of particular infectious diseases. The
mere threat of bubonic plague or cholera was enough to close ports or impose quarantine
measures, both of which impeded the exchange of goods and people. In 1851, diplomats
and physicians from 11 European countries met in Paris at the first International Sanitary
Conference. They sought to create a uniform quarantine policy that would simultaneously
prevent any interruptions of trade. This first conference failed to produce any agreements,
thanks to disagreements over disease etiology, but it did help set the stage for future
international health diplomacy efforts14. Over the next 50 years, an additional ten
international sanitary conferences took place. Each conference attracted more delegates,
and did eventually lead to the creation of internationally agreed-upon standards for
quarantine and disease control measures15.
These conferences eventually led to the creation of bodies like the World Health
Organization and harmonized health policies among most nations. Despite these
successes, they represented a narrow conceptualization of health diplomacy and one quite
different from today. Three main differences stand out. First, these early efforts at health
diplomacy focused on disease rather than health. The agreements that emerged from
14 Alexandra Minna Stern and Howard Markel, “International efforts to control infectious
diseases, 1851 to the present,” Journal of the American Medical Association 292 (2004),
1475.
15 Norman Howard-Jones, The Scientific Background of the International Sanitary
Conferences, 1851-1938 (Geneva: World Health Organization, 1975).
these early international conferences focused solely on three diseases: cholera, yellow
fever, and bubonic plague16. Specific diseases, rather than a general concern for human
well-being, motivated this cooperation. Part of this may derive from understandings of
health and illness that dominated at the time. Especially during the first conferences, few
physicians accepted germ theory as an explanation for disease. Instead, many saw a
connection between personal morality or individual behavior and susceptibility to
infectious disease17. Such a mindset would not be conducive to a broader
conceptualization of health. Second, health diplomacy focused on preventing the spread
of particular diseases instead of preventing the actual diseases themselves. Again, this
likely arose initially from a lack of understanding about where cholera, yellow fever, and
bubonic plague came from. As physicians understood this better, though, the international
community did not press for a greater emphasis on prevention itself. Third, international
cooperation on disease prevention focused on those illnesses that threatened to interrupt
commerce. The diseases that threatened to exact economic consequences received
attention; others were essentially ignored. This also meant that the regulations addressed
the economic concerns of the dominant European commercial powers at the time.
In its more contemporary manifestation, health diplomacy refers to “mechanisms to
16 Dr. Margaret Chan, “Health Diplomacy in the 21st Century,” Address to Directorate for
Health and Social Affairs of Norway (13 February 2007),
, accessed 8
January 2008.
17 Sylvia Noble Tesh, Hidden Arguments: Political Ideology and Disease Prevention
Policy (New Brunswick, NJ: Rutgers University Press, 1988).
manage the health risks that spill into and out of every country”18. Doing so requires
“multi-level and multi-actor negotiation processes that that shape and manage the global
policy environment for health”19. A recent conference devoted to the issue defined global
health diplomacy simply as “political change activity that meets the dual goals of
improving global health and maintaining and improving international relations abroad,
particularly in conflict areas and resource-poor environments”20. These definitions, while
similar to the previous one on its surface, take a more holistic view of both health and the
international community. It moves beyond an explicit focus on particular illnesses and
instead recognizes how various manifestations of ill health can have negative
consequences for the international community. Drager and Fidler, for example, concern
themselves a great deal with the connections between health and international economics,
but they do so from a perspective that recognizes that healthier countries are more
economically productive and better able to engage with others on that level21. Health, in
this way, becomes a tool for promoting economic growth. The previous conceptualization
18 Nick Drager and David P. Fidler, “Foreign policy, trade, and health: at the cutting edge
of global health diplomacy,” Bulletin of the World Health Organization 85 (2007), 162.
19 Ilona Kickbusch, Gaudenz Silberschmidt, and Paulo Bass, “Global health diplomacy:
the need for new perspectives, strategic approaches, and skills in global health,” Bulletin
of the World Health Organization 85 (2007), 230.
20 University of California Institute on Global Cooperation and Conflict, “Global Health
Diplomacy—
Background,” ,,
accessed 8 January 2008.
21 Drager and Fidler, 145.
of health diplomacy saw disease as an economic impediment.
Current health diplomacy tends to manifest itself in three different ways. The first could
be described as “disaster diplomacy.” This entails going into areas ravaged by natural
disasters like earthquakes, tsunamis, and droughts to provide relief22. Such occurrences
often lead to extensive social chaos, but they also provide opportunities for outside
interveners to burnish their images within the affected region. The United States’ health
interventions in places like Banda Aceh and Thailand after the 2004 tsunami not only
provided much-needed medical relief, but also fit into a larger “hearts and minds”
strategy in the region23. The second form concerns international agreements and
conventions designed to bring many parties together to address health concerns. These
may focus on specific diseases, such as UNAIDS and the Global Fund to Fight AIDS,
Tuberculosis, and Malaria, or may address health more broadly, like the Alma-Ata
Conference of 1979. These efforts bring state and non-state actors together in some sort
of international forum to collaboratively address health concerns. The final form, and the
one on which I focus in this paper, deals with one country or a group of countries
22 See Scott C. Ratzen, “Beyond the 2004 tsunami: health diplomacy as a response,”
Journal of Health Diplomacy 10 (2005), 197-198 and Ilan Kelman, “Hurricane Katrina
disaster diplomacy,” Disasters 31 (2007), 288-309.
23 This is not to suggest that the United States’ response was motivated solely by
geopolitical concerns; rather, it is to acknowledge that such geopolitical concerns played
some role in motivating the immediate response. See William Vanderwagen, “Health
diplomacy: winning hearts and minds through the use of health interventions,” Military
Medicine 171 (2006), 3-4.
working to develop the health care infrastructure in a particular country or group of
countries. It differs from the second form of health diplomacy because it is specifically
targeted at capacity building and prevention efforts. They are not spurred by a specific
disease outbreak or immediate health crisis, but rather by recognition of the need to
develop a country’s infrastructure so that it could effectively respond to a crisis should
one arise.
Governments increasingly recognize how successful health diplomacy can be a key
component of soft power. Providing health services to those in need not only improves a
country’s reputation, but can also be done far more inexpensively than traditional hard
power means. The United States’ Presidential Emergency Plan for AIDS Relief
(PEPFAR) has provided US$15 billion to combat AIDS worldwide over the past five
years—the largest expenditure for a single disease by a single country in history. Nye
praised this initiative as contributing significantly to the country’s soft power and
counteracting some of the more negative elements of American foreign policy in the past
decade24. Tommy Thompson, the former United States Secretary of Health and Human
Services, promoted the use of what he termed “medical diplomacy” as an important
element of the government’s anti-terrorism strategy. Discussing the usefulness of
“exporting medical care, expertise, and personnel to those that need it most,” Thompson
wrote in a Boston Globe column, “America has the best chance to win the war on terror
and defeat the terrorists by enhancing our medical and humanitarian assistance to
vulnerable countries. By delivering hope we will deliver freedom… These are the
24 Nye, “Soft power and American foreign policy,” 268.
battlefields where we will be able to win the war on terror -- at a relatively low cost.”25.
In another interview, Thompson remarked, “What better way to knock down the barriers
of ethnic and religious groups that are afraid of America than to offer good medical
policy and good health to these countries?”26 As Thompson conceptualized it, medical
diplomacy would allow the United States to improve its image in regions of the world
currently hostile to it while also providing much needed medical services. Providing
these services would make America more attractive in the eyes of the residents of those
countries, thereby advancing the United States’ diplomatic interests in fostering stability
and eliminating support for terrorist organizations. This strategy has continued under
Thompson’s replacement, Mike Leavitt. Leavitt describes how the United States
government’s efforts at promoting health and reducing the HIV/AIDS burden in South
Africa and Rwanda have led to an outpouring of support among local residents for the
United States27. Commenting on the efforts by Leavitt, Fortin notes, “it [health
diplomacy] is critically important in demonstrating who we are as a nation and who we
want to be as global citizens”28. Supporting health care infrastructure demonstrates the
25 Tommy G. Thompson, “The cure for tyranny,” Boston Globe (24 October 2005),
_for_tyranny/>, accessed 8 January 2008.
26 John K. Iglehart, “Advocating for medical diplomacy: a conversation with Tommy G.
Thompson,” Health Affairs 10 (2004), 264.
27 Mike Leavitt, “Rural Rwanda,”
, accessed 8
January 2008.
28 Fred Fortin, “Health diplomacy and America’s ‘soft power’”,
United States’ concern for the general welfare of humanity, as opposed to intervening
only in ‘strategically important’ countries. Building this support now will build good will
toward the United States, allowing the country to further its diplomatic initiatives later
with the support of these countries.
Health diplomacy can thus figure prominently in at least two of the three components of
soft power. By making the provision of health care an important element of a country’s
foreign policy, it will allow a country to demonstrate its moral authority. Further, it
provides a concrete demonstration of a country’s political values; in this case,
demonstrating that all people deserve adequate health care. Providing health care could
also make a country’s culture more attractive if the care reflects upon the provider’s
country in some way. For instance, if the provider fails to offer care necessary or
appropriate to the needs of the local population, that may appear presumptuous,
condescending, and perhaps even imperial. In essence, health diplomacy can show the
receiving countries that the providing country respects and cares for people and has
interests beyond its own narrow economic and military needs.
II. China, Africa, and health diplomacy in history
Chinese diplomatic involvement in Africa goes back to the 1950s29. In many ways, China
,
accessed 8 January 2008 (emphasis in the original).
29 I do not wish to imply that no Sino-African relationships existed prior to the 1950s.
Indeed, Philip Snow’s remarkable book, The Star Raft, exhaustively details the activities
sought to frame its early interactions with African governments and, in particular, anticolonial
movements as a counterweight to the perceived hegemonies of both the United
States and the Soviet Union. The Chinese government portrayed itself to African
constituencies as a patron who rejected the imperial mandates of Western powers and
understood the unique struggles of ‘peasant movements’ unlike the Soviet Union. Sino-
African relations in the 1950s and 1960s saw the Chinese attempting to affirm its own
brand of Maoist communism as the most appropriate model for development and anticolonialism.
It also provided financial, logistical, and training support for revolutionary
movements on the continent. This relationship continued through the 1970s, but its
emphases changed. Instead of necessarily trying to promote its vision of communism,
Chinese support to Africa focused more on trying to keep the Soviet Union in check30. It
was less a pro-active strategy to promote a specific outcome and more of a reactive one
designed to prevent a competitor from getting too far ahead. To take one example, the
Chinese government supported the Zimbabwe African National Union (ZANU), headed
by Herbert Chitepo and, later, Robert Mugabe, after the Zimbabwe African People’s
Union (ZAPU), under the leadership of Joshua Nkomo, started receiving support from the
Soviet Union. Many have interpreted this move as based less on ideological affinities and
of Chinese traders in Africa going back to 1414. Most of the first 500 years of contact
between the two, though, focused largely on commercial interactions. See Philip Snow,
The Star Raft: China’s Encounter with Africa (New York: Grove Press, 1988).
30 Joshua Eisenman, “China’s post-Cold War strategy in Africa: examining Beijing’s
methods and objectives”, in Joshua Eisenman, Eric Heginbotham, and Derek Mitchell,
eds., China and the Developing World: Beijing’s Strategy for the Twenty-First Century
(Armonk, NY: M.E. Sharpe, 2007), 29-31.
more on pragmatic concerns about countering Soviet influence31.
Chinese involvement in Africa went beyond providing money and training to anticolonial
movements; it extended into supporting infrastructural development throughout
the continent. One of the key elements of this strategy was medical cooperation. In 1963,
Zhou Enlai dispatched the first Chinese medical teams to Algeria32. This inaugurated
Chinese efforts to support African health care systems by providing medical personnel,
equipment, and supplies throughout the continent. In some instances, the arrival of
medical teams coincided with other Chinese infrastructure- or economics-based
diplomatic involvement in Africa; for example, Chinese medical teams arrived in the
early 1970s in Tanzania along with laborers working on the TanZam Railway33. More
often, though, the deployment of medical teams followed treaty negotiations between
China and the receiving state absent any ostensible economic benefit. In a number of
instances, the arrival of Chinese medical teams followed the host country’s inability to
maintain its previous health care commitments34. Instead, the Chinese government sought
to improve its standing within the international community and build support among
developing nations. It has sought to develop the health care infrastructures in African
states without imposing a uniform vision of those infrastructures and through a strong
emphasis on development based on the country’s own unique characteristics and locally-
31 Joshua Eisenman, “Zimbabwe: China’s African ally,” China Brief 5:15 (2005), 9.
32 Eisenman, “China’s post-Cold War strategy,” 43-44.
33 Michael Jennings, “Chinese medicine and medical pluralism in Dar es Salaam:
globalization or glolocalization?” International Relations 19 (2005), 461.
34 Ibid.
appropriate technologies35. 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. To facilitate the development of long-standing ties, the Chinese national
government did not arrange the logistical details of these deployments. The treaties were
negotiated at the national level, but the implementation occurred at the provincial level.
Particular Chinese provinces were linked with one or more particular African countries36.
Yunnan Province sends its medical personnel to Uganda, while Zambia, Ethiopia, and
Eritrea receive medical teams from Henan Province, for instance37. It was the provincial
government’s responsibility to recruit personnel, send equipment, and ensure smooth
exchanges.
Under the terms of most of the medical cooperation agreements, the receiving state paid
the expenses for the medical team. These included international airfare, 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
35 Bates Gill and Yanzhong Huang, “Sources and limits of Chinese ‘soft power’”,
Survival 48:2 (2006), 20 and Padraig R. Carmody and Frances Y. Owusu, “Competing
hegemons? Chinese versus American geo-economic strategies in Africa,” Political
Geography 26 (2007), 508.
36 Ambassador David H. Shinn, “Africa, China, and health care”, Inside AISA 3/4
(October/December 2006), 15.
37 Drew Thompson, “China’s soft power in Africa: from the ‘Beijing Consensus’ to
health diplomacy,” Asia Brief 5:21 (2005), 4.
through loans or grants. More often than not, though, these costs came directly from the
national health care budget38.
Most commentators remarked rather positively on Chinese medical cooperation in the
1960s and 1970s. Alan Hutchison visited a number of medical clinics sponsored by the
Chinese government throughout the continent in the early 1970s. He found that rural
Chinese medical teams represented one of the most successful forms of aid in Africa. The
so-called “barefoot doctors” adapted well to local conditions, demonstrating an ability to
provide quality medical care in resource-poor settings. Significantly for Hutchison, the
Chinese medical teams focused less on emergency medical care, instead focusing on
bringing basic preventative care to rural areas that had previously lacked any such care39.
Hutchison saw this as a positive sign that Chinese health diplomacy could promote the
sustainable development of the receiving country’s health care infrastructure. Indeed, it is
difficult to argue that the Chinese medical teams have not had a positive effect
throughout the continent. Since that first medical team arrived in Algeria, more than
15,000 Chinese medical personnel have served in 47 different African states and treated
180 million cases of illness and disease40. This represents a significant contribution to the
continent’s health and its health care infrastructures.
38 Thompson, “China’s soft power,” 3.
39 Alan Hutchison, China’s African revolution (Boulder: Westview Press, 1975),
220-221.
40 Eisenman, “China’s post-Cold War strategy,” 43-44 and Carmody and Owusu,
“Competing hegemons?”, 508.
Over time, Sino-African relations retreated to the backburner. China paid less and less
attention to Africa as it sought to find a place in the international marketplace. African
markets held little allure or promise for Chinese manufacturing interests, so they fell by
the wayside. Africa may not have ever been the primary focus of Chinese foreign policy,
but the continent lost what little relevance it had by the 1980s. One commentator went so
far as to remark, “It is hard to make a case that Africa matters very much to China…they
[Africans] count for little in the overall scheme of Chinese foreign policy objectives”41.
In recent years, Africa has regained a level of prominence in China’s overall foreign
policy strategy. The growing amount of attention paid to Africa has coincided with a
resurgence of health diplomacy.
III. Sino-African health diplomacy today
Over the past two decades, the Chinese government has engaged in a concerted effort to
portray itself as an active and responsible member of the international community. Some
of this is post-Tiananmen damage control; the Chinese government wants to prove to the
rest of the world that it can abide by the ideals undergirding the international community.
To do this, it has taken a greater effort to build bilateral relations with an increasing array
of countries, joined regional and international organizations, and demonstrated a
willingness to participate in international economic forums. At the same time, though,
Chinese government efforts have paid particular attention to developing countries in an
41 Gerard Segal, “China and Africa,” Annals of the American Academy of Political and
Social Sciences 519 (1992), 115.
effort to blunt international criticism of its policies and practices42. In bodies like the
United Nations, developing countries far outnumber developed ones. By building
relations with developing countries, the Chinese government hopes to have the numerical
clout to prevent the organization from passing General Assembly resolutions that
condemn its actions and policies.
This strategy has led to a resuscitation of earlier rhetoric about the natural ties between
the developing world and China. Indeed, Huang and Ding note that China has been
“particularly deft at using foreign aid to communicate favorable intentions or evoke a
sense of gratitude” among African states43. The Chinese government has, in statements to
developing countries, has frequently counted itself among their numbers and called itself
the leader of the developing world. It has also positioned itself as the only viable source
of support to challenge the neo-imperialism of Western states. It has a promoted a
strategy of non-interference in domestic affairs, emphasizing that its foreign aid comes
with none of the conditionality imposed by the United States44. Along with the lack of
conditionality, the Chinese government has also targeted a significant portion of its aid
42 Denis M. Tull, “China’s engagement in Africa: scope, significance, and consequences,”
Journal of Modern African Studies 44 (2006), 460-461.
43 Huang and Ding, “Dragon’s underbelly,” 37.
44 Ian Taylor, China and Africa: engagement and compromise (New York: Routledge,
2006), 13-15. For some perspective on the receptivity of African states to this language,
see Jeremy Youde, “Why Look East? Zimbabwean foreign policy and China,” Africa
Today 53:3 (2007), 3-19.
toward infrastructure development45.
Health diplomacy is just one element of China’s increased engagement with Africa, but it
plays a prominent role. Government leaders from China and 45 African states met in
Beijing in October 2000 for the inaugural China Africa Cooperation Forum (CACF). At
this time, 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.
Three years later, when the CACF re-convened in Addis Ababa, the Chinese government
made more explicit health diplomacy promises. It highlighted the treatment and
prevention of disease as one of its priority areas, pledging additional funds for these
efforts46. Health also featured prominently at the third CACF 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 programs in its African aid efforts47. At this same meeting,
the Chinese government pledged to build 30 hospitals in Africa, provide US$37.5 million
in grants for anti-malarial drugs, and develop 30 demonstration centers for the treatment
and prevention of malaria. It also renewed its commitment to send medical teams to the
best of its ability for the next three years48.
45 Joshua Eisenman and Joshua Kurlantzick, “China’s African strategy,” Current History
691 (2006), 221.
46 Sutter, Chinese foreign relations, 373.
47 Ibid.
48 “China, Africa vow closer cooperation in fighting HIV/AIDS: action plan,” People’s
Daily, 6 November 2006.
In releasing its Africa policy in 2006, the Chinese government highlighted four healthrelated
priorities in its relations with the continent. These were:
-Emphasizing the need to develop and promote effective treatments for
malaria,
-Enhancing exchanges of medical personnel and information between
China and Africa,
-Sending medical teams and equipment to improve facilities and train
doctors throughout the continent, and
-Assist with efforts into researching the usefulness of traditional medicines
in treating and preventing HIV/AIDS49.
These health diplomacy efforts play themselves out in a number of different ways. Most
prominently, Chinese provincial governments continue to send medical teams to their
assigned African countries. After dwindling in the 1980s, Chinese medical teams have
been increasingly deployed throughout the continent. In 2003, 860 Chinese medical
personnel were serving in 35 teams in 34 African states50. Two years later, the number of
Chinese medical personnel in Africa topped 900. In addition to the traditional medical
teams, the Chinese government started to include its medical personnel on United
Nations peacekeeping missions in Africa. Nearly 900 Chinese medical personnel served
, accessed 17
January 2008.
49 Shinn, “Africa, China, and health care,” 14.
50 Eisenman, “China’s post-Cold War strategy,” 44.
on 8 UN-sponsored African peacekeeping missions in 200551.
Deploying medical personnel is perhaps the most obvious and apparent element of
China’s health diplomacy strategy, but it is not the only one. Building medical clinics to
serve local populations, donating pharmaceuticals, and occasionally even providing
medical equipment have all played increasingly important roles in these efforts.
Interestingly, while the Chinese government provides some of the medical clinics as
assistance projects to countries in need, some are explicitly designed to be commercial
ventures52. These for-profit ventures may not exactly conform to the same idea of health
diplomacy as the donated clinics, but they do further the objective of providing health
care in underserved areas of Africa to help improve China’s stature on the continent. Few
patients will necessarily know whether a particular clinic comes from China as a nonprofit
or for-profit enterprise; the patients instead recognize that they now have access to
health care. Shinn notes that this more expansive health diplomacy with clinics, drugs,
and equipment has additional benefits for China. Donating pharmaceuticals is a “clever
and low-cost way to introduce Chinese-made medication to the African market”53. There
is also increased interest among a number of African governments on collaborating on
research projects with Chinese medical personnel and scientists on using African herbal
medical treatments to treat HIV/AIDS54.
51 Robert G. Sutter, Chinese foreign relations: power and policy since the Cold War
(Lanham, MD: Rowman and Littlefield, 2008), 375.
52 Shinn, “Africa, China, and health care,” 15.
53 Ibid.
54 Shinn, “Africa, China, and health care,” 16.
Not only does providing health care make China look better in the eyes of everyday
Africans, but it also inclines them to trust medical products produced in China. In this
way, China’s health diplomacy soft power efforts also offer the country an economic
payoff. That does not negate the soft power aspects of China’s health diplomacy efforts;
in fact, it reinforces them. Soft power works through the power of attraction, and that
attraction can lead others to take certain diplomatic, cultural, or economic decisions.
Attraction leads to trust, and trust can encourage economic decisions. Soft power’s
success in attracting an economic benefit reinforces the usefulness of soft power.
By its nature, it can be difficult to determine exactly when and how soft power operates
to alter the behavior of another state. Soft power works through attraction in a general
sense. It rarely has a specific policy objective attached to it; rather, it is about making a
state look better in the eyes of others. Since there is not a specific policy attached to these
efforts, the cause-and-effect relationship between soft power and state behavior is
somewhat more tenuous. No African ambassador would proclaim in the United Nations
General Assembly that it was voting with the People’s Republic of China because the
Chinese government had announced the shipment of one million doses of anti-malarial
drugs. In addition, soft power is a long-term strategy. It focuses less on altering specific
state behaviors at a given time and more on effecting a state’s reputation in other states.
Indeed, it is entirely plausible that members of a government may not necessarily connect
their favorable views of China to elements of soft power.
These difficulties do not negate the importance and usefulness of soft power. Indeed, we
can see some evidence of the success of China’s soft power strategies. A worldwide
survey by the Pew Global Attitudes Project found that majorities or pluralities of citizens
in 10 African states thought that China had at least a fair amount of influence on their
countries. In Mali and Cote d’Ivoire, respondents indicated that China’s influence was at
least on the same level as the United States. Indeed, throughout the continent, more
people indicate that China’s influence in their country is positive than say that about the
United States’ influence55.
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 muchneeded
services to a large swath of the population in Africa, but it also reaches far more
people than other outreach programs 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”56. Soft power,
remember, seeks to make a country’s culture and politics attractive and worthy of respect.
In this instance, we see how providing health services allows the Chinese government to
grow in stature among the people and government leaders throughout the African
55 Pew Global Attitudes Project, “Summary of Findings: Global Unease with Major
World Powers,” 27 June 2007, ReportID=256>, accessed 17 January 2008.
56 Thompson, “China’s soft power in Africa,” 2.
continent.
IV. Limitations on Chinese health diplomacy
Chinese health diplomacy appears to further the country’s soft power and its diplomatic
ambitions, but it is not a fail-proof strategy. Two important limitations—one coming
from China, the other coming from Africa—could undermine this strategy.
First, pressures on the Chinese medical system may prevent it from continuing to deploy
medical teams throughout the continent. The 2006 CACF pledges obliquely acknowledge
these limitations, with the Chinese government offering to send medical teams to the
extent it could. Increased prosperity within China itself has increased demands on the
medical system, and Chinese citizens are increasingly demanding better health care57.
With a finite amount of medical resources available, increased demands for better health
care at home will likely lead to a questioning of the usefulness and appropriateness of
sending Chinese medical personnel to Africa at the expense of providing health care in
China itself. Popular pressures question the usefulness and appropriateness of sending
medical technologies and personnel abroad when the domestic Chinese population often
lacks access to these same technologies and personnel.
At the same time, the increased earning potential of medical personnel in China means
fewer have expressed an interest in spending two years in Africa, often living in less than
ideal circumstances. Some provinces have reported increasing difficulty in staffing their
57 Eisenman, “China’s post-Cold War strategy,” 44.
medical teams58. Eisenman suggests that difficulties in recruiting medical personnel will
lead the Chinese government to send more pharmaceuticals and medical technology
instead of actual doctors and nurses59. This may be a logical and rational reaction to the
shortage of available personnel, but it will also likely decrease health diplomacy’s
benefits. Without the physical presence of people, it is less likely that patients will
recognize that the drugs and medical equipment come from China instead of the United
States or somewhere else. Having bodies on the ground provides tangible evidence of the
commitment China has made to African health care systems. Medical technology and
drugs seem unable to replicate that evidence.
Second, some evidence suggests a growing backlash in various parts of Africa against the
increasingly pervasive Chinese presence. Pro-democracy and human rights activists in
Africa (and the West) have charged the Chinese government with propping up
authoritarian regimes and undermining efforts to increase freedom throughout the
continent60. The willingness of the Chinese government to provide support to dictatorial
leaders may “undercut[] its efforts to become a responsible power”61. Others allege that
Chinese-sponsored infrastructure projects are predicated upon African states giving
China access to natural resources as an explicit quit pro quo62. Trade unions have
58 Thompson, “China’s soft power in Africa,” 4-5.
59 Eisenman, “China’s post-Cold War strategy,” 44.
60 Craig Timberg, “In Africa, China trade brings growth, unease,” Washington Post (13
June 2006), A14.
61 Huang and Ding, “Dragon’s underbelly,” 38.
62 Ibid.
chastised China for paying low wages, offering little job security to local workers, hiring
Chinese workers even when qualifies local employees are available, and driving local
companies out of business63. Michael Sata, a Zambian opposition leader and candidate in
the 2006 presidential election there, went even further, exclaiming, “Zambia is becoming
a province—no, a district—of China…We’ve removed one foreign power, and we don’t
want another foreign power here, especially one that is not a democracy”64. These actions
may reduce the willingness of African states to accept China’s medical diplomacy efforts,
as they fear the damage to their reputations are higher than the benefits.
Ostensibly, China’s soft power strategy seeks to counteract these negative impressions
and encourage Africans to think about China in more positive terms. Indeed, the Chinese
government, in its official Africa policy, emphasizes, “Sharing similar historical
experience [sic], China and Africa have all along sympathized with and supported each
others in the struggle for national liberation and forged a profound friendship”65.
However, the upsurge in negative feelings about China and its intentions in Africa have
corresponded with greater Chinese investment in and activity on the continent. This
suggests that China’s African strategy may be working at cross-purposes or lack
coherency. While the average man and woman in Africa may appreciate China providing
63 “African backlash against China,” Asia Times (20 October 2006)
64 Cited in Yaroslav Trofimov, “In Africa, China’s expansion begins to stir resentment,”
Wall Street Journal (2 February 2007).
65 Ministry of Foreign Affairs of the People’s Republic of China, “China’s Africa Policy,”
January 2006. , accessed 21 January
2008.
medical care, they increasingly resent China’s economic and political activities on the
continent. China’s attempts to make their culture and ideals more attractive are not
translating into more positive feelings and attitudes toward China by Africans. A recent
report published by the Center for Strategic and International Studies highlighted this
oversight. Analyzing growing Sino-African ties, the CSIS report identified a failure to
take “evolving Africa popular opinion –the ‘African street’” into account66. Ignoring the
attitudes and opinions of everyday Africans could severely undermine China’s attempts
to forge a closer strategic relationship with Africa. A successful soft power strategy will
thus not only need to carefully consider public opinion, but also provide a means for
connecting China’s health diplomacy efforts on the continent with its larger strategic,
economic, and attitudinal goals.
V. Conclusion
China’s embrace of health diplomacy in Africa in recent years connects back to earlier
efforts to promote itself as a vanguard alternative to leading Western states. In its more
modern manifestation, health diplomacy figures prominently as an important element of
China’s soft power. Providing medical care and building the health care infrastructure of
African states improves China’s standing among developing countries and bolsters its
status as a credible alternative to the dictates of Western powers.
66 Bates Gill, Chin-hao Huang, and J. Stephen Morrison, China’s Expanding Role in
Africa: Implications for the United States (Washington: CSIS, 2007), vi.

paper

2008-05-06T08:42:00.000-07:00

EMERGING NORMS IN NATIONAL HEALTH GOVERNANCE: AN EXAMINATION OF NEW AUTHORITY STRUCTURES AND THE GROWING IMPORTANCE OF NEW FORMS OF GOVERNANCE IN INDIA
Sophia N. Johnson, Ph.D. Candidate
Division of Global Affairs
Rutgers, The State University of New Jersey
Paper prepared for ISA’s 49th Annual Convention: Bridging Multiple Divides
San Francisco, CA, USA, March 26-29, 2008
This is a working paper. Please do not cite without the written permission from the author, available at sophiaj@pegasus.rutgers.edu (03/25/2008)
1
INTRODUCTION
The changing nature and role of the territorial state is a central preoccupation of postinternational thinking. James N. Rosenau coined the term "post internationalism" to describe "an apparent trend in which more and more of the interactions that sustain world politics unfold without the direct involvement of nations and states."1 Postinternational theory accounts for the centralizing and decentralizing tendencies on the world stage after 1945; for the shifting orientations that have been transforming authority relations among actors; and for the dynamics and structural bifurcation shaping the arrangements through which diverse actors pursue their goals.2 Under this framework, governance in general and national governance in particular has shifted. Governance can be defined as "the actions and means adopted by a society to promote collective action and deliver collective solutions in pursuit of common goals."3 National governance then, "is not only a consequence of domestic politics and structures but a cause … international relations and domestic politics…are so interrelated that they should be analyzed simultaneously, as wholes."4 Together, these terms apply to what Rosenau describes as the ‘mobius-web governance,’ which accounts for the diversity of micro-macro interactions that contribute to governance in both state centric and multi-centric worlds. Consequently, the dynamics of Rosenau’s described fragmegration, and perhaps especially the complexities inherent
1 Rosenau, James N. Turbulence in World Politics: A Theory of Change and Continuity. Princeton: Princeton University Press, 1990. pp. 6.
2 Rosenau, James N. Turbulence in World Politics: A Theory of Change and Continuity. Princeton: Princeton University Press, 1990. pp. 7.
3 Dodgson, Richard and Kelly Lee. "Global health governance: a conceptual review" in Global Governance: critical perspectives edited by Rorden Wilkinson and Steve Hughes. London: Routledge, 2002. pp. 93.
4 Ferguson, Yale H. and Richard W. Mansbach. Remapping Global Politics: History’s Revenge and Future Schock. Cambridge University Press, 2004. pp. 93.
2
in the extensive disaggregation of authority it has fostered, brings forward the question of whether governance on a national scale can be achieved in the emergent epoch.
India is an important case for examining emerging norms in national health governance. While the locus of political authority is territorially bounded to sovereign states, national economic, social, and security relations have internationalized through key networks of international organizations, strategic alliances, and nonstate actors. This is especially true as we see what happens as long term global dynamics and short term immediate circumstances interact in such a way that any unexpected development can serve as a tipping point and trigger collective actions seeking to bring about basic changes.5 Old rules and arrangements that prevailed throughout the industrial era are giving way to new forms of governance, and without the presence of formal state or interstate institutions. Some states have yielded to the pressures of new actors and have cooperatively formed both formal and informal relationships, an avenue through which the spreading of norms is translated into mechanism of governance.6 Health governance is broadly interpreted as the "action and means adopted by a society to organize itself in the promotion and protection of health of its population."7 In turn, the "pressures generated by bottom-up governance has given rise to top down and side-by-side governance that has become a vast network encompassing all levels of governance and diverse flows of authority."8
5 Rosenau, James N. Distant Proximities: Dynamics beyond globalization. Princeton: Princeton University Press, 2003. pp. 291.
6 Rosenau, James N. Distant Proximities: Dynamics beyond globalization. Princeton: Princeton University Press, 2003. pp. 393.
7 Dodgson, Richard and Kelly Lee. "Global health governance: a conceptual review" in Global Governance: critical perspectives edited by Rorden Wilkinson and Steve Hughes. London: Routledge, 2002. pp. 94.
8 Rosenau, James N. Distant Proximities: Dynamics beyond globalization. Princeton: Princeton University Press, 2003. pp. 398.
3
How India defines, let alone achieve national health governance in this emerging epoch, remains an enduring challenge. In this paper, I take a first step in analyzing the emerging debate by reviewing the meaning and defining the new features of national governance, and examining the changes in long standing patterns of national health governance in India, in particular. The study looks at the flux and transitions, and assesses the particular impacts on governance when national health is transformed through new authority structures - and the fundamental challenge this poses for promoting and protecting health in a strong nation-state is explained. From this point of departure, the theoretical context of this research lies at the intersection of governance and authority in global politics. In addition, I begin to analyze the future of governance, authority and health in developing countries, of various historical experiences with one central question: How do we account for the role of new authority structures, and should we envisage this as a normative change in governance?
RESEARCH DESIGN
This research undertakes a case study approach, with aims to examine the normative discourse on governance, authority and health across India. The overarching goal is to identify common factors that explain why and how these norms, in the form of network actors, are situated in a strong nation state. Defined here, networks are an international body of actors, which include international organizations, strategic alliances, and nonstate actors. Collectively, these arrangements deploy a form of authority whose effects are important for understanding not just the behavior of networks, but also for
4
assessing the governance of states.9 In addition, the study seeks to draw lessons from the national health governance debate in India that might well improve governance in other sectors or countries. The study examines emerging norms in national health governance at three sites: Chandigarh, Punjab; Kolkata, West Bengal; and, Bhubaneswar, Orissa.
Rather than using large samples and following a rigid protocol to examine a limited number of variables, this case study involves an in-depth, longitudinal examination of India. The focus is on systematically collecting data, analyzing information and reporting the results. This research cuts across disciplines, and mixes quantitative and qualitative evidence to establish the reasons behind various aspects of national health governance. The data for this analysis will be abstracted from three key sources: first, my own comprehensive survey assessment of health governance; second, the 2006 World Bank Development Policy Review of India; finally, three recent Government of India reports: Eighth and Tenth Five-Year Plans, Census of India, 2001, and the Ministry of Health & Family Welfare annual reports of 1992-93 and 2005-2006. The objective is to define national health governance, and determine the role of new authority structures in health. In addition, I will examine whether new authority structures speak and act as the postinternational theory predicts.
First, since there is no one accepted methodology for quantifying governance indices, I rely on the World Bank’s Worldwide Governance Indicators (WGI) project, World Governance Assessment and the World Health Organization’s 26-baseline indicators, to compose my own governance assessment survey. My survey comprises 30 questions, and is divided into six parts: voice and accountability; political stability and
9 Cutler, Claire A. "Private international regimes and interfirm cooperation" in The Emergence of Private Authority in Global Governance by Rodney Bruce Hall and Thomas J. Biersteker (editors). Cambridge: Cambridge University press, 2002. pp. 23.
5
absence of violence; network actor effectiveness; regulatory quality; rule of law; and, control of corruption. The questions were designed to provide insight into availability, reliability and validity of current data on network actor activity, and to further explain how different countries understand national health governance. The survey endeavors to capture opinions on governance perceptions, as perceptions may often be more meaningful than objective data, especially when it measures public faith in institutions.10 One-hundred surveys will be distributed to academics, officials in international organizations concerned with governance, health administrators, and representatives of both the private and public sectors in Chandigarh, Punjab; Kolkata, West Bengal; and, Bhubaneswar, Orissa.
Second, this study evaluates the role of emerging authority structures, beginning with a look at the World Bank’s India Development Policy Review (DPR) 2006 titled, "Inclusive Growth and Service Delivery: Building on India’s Success." The DPR is one of the World Bank’s core analytical tools. The report, produced by the Bank every few years, helps countries frame key development challenges.
Third, an important consideration for this study is to examine how the State, looking inward, views it own system of national health governance. For this, I turn to the Government of India (GOI). I will begin by reviewing the Eighth and Tenth Five-Year Plan’s published by the Planning Commission. These Plans have been instrumental for bringing about planned socio-economic development in India. Second, I will review the Census of India’s 2001 report, which estimated India had reached a benchmark 1.1
10 Daniel Kaufman, Aart Kraay, Massimo Mastruzzi. "Governance Matters VI: Aggregate and Individual Governance Indicators, 1996-2006. (July 2007) World Bank Policy Research Working Paper No. 4280. Uploaded 3/4/08 from Social Science Research Network http://papers.ssrn.com/sol3/papers.cfm?abstract_id=999979#PaperDownload
6
billion population. This extraordinary figure also puts the combined populations of Punjab, West Bengal and Orissa at 141 million. Due to the sheer size of the citizenry in these states, I will examine the extent to which new authority structures in the periphery cannot be ignored. Finally, the Ministry of Health & Family Welfare 1992-93 and 2005-2006 reports will be examined to assess emerging dimensions of governance in health and development. Immediately following the 1991-economic reforms, the World Bank was the principle network actor contributing to health. By 2005-2006 however, international cooperation in health from external agencies more than quadrupled for the Ministry of Health & Family Welfare.
LITERATURE REVIEW
Until recently, most explanations of international behavior have concentrated on the self interested motivations of individual states, with little recognition by states of the authority of new structures operating in the system. The literature wrestles with the complexity of governance, and forces an examination of actions within and between states. Just as the market and the state have their supporters, normative action is sometimes advocated as a simple remedy for a wide range of governance problems.11 The rules defining such organization and its functioning can be formal or informal to prescribe and proscribe behavior.12 The governance mechanism employed in this process can in turn be situated at the local, national, regional, international and the global level.
11 Dreze, Jean and Amartya Sen. India: development and participation. Oxford: Oxford University Press, 2002. pp. 60.
12 Dodgson, Richard and Kelley Lee "Global health governance: a conceptual review" in Global governance: critical perspectives edited by Rorden Wilkinson and Steve Hughes. London: Routledge, 2002. pp. 94.
7
In other instances, national health governance may rely on mechanisms such as custom, common law, cultural norms, and values that are not legally formalized.13
This notion of national authority derives from Weberian conceptions of the state. There is a presumption within much of international relations theory, that the domain of the domestic is fundamentally different from the domain of the international. For Weber however, the essence of the state is its ability to claim "the monopoly of the legitimate use of physical force within a given territory." Because of their claims to legitimate authority, most states "can rely on the habitual obedience of their citizens by establishing legal codes in which the threat of physical coercion is only implicit."14 This ability to rely upon legitimate authority for habitual obedience is largely absent in the international system however. Instead, international politics takes place in a realm where anarchy reigns and states act in their own best interest and sometimes employ force to achieve their objectives. States are both the source and exclusive location of legitimate public authority.15 In sum, the state is no longer the leading force providing advantage to regions, ethnic groups and classes in health. India, in common with an increasing number of states responds to issues produced by uneven economic development and social change with the support of network actors.
13 Dodgson, Richard and Kelley Lee "Global health governance: a conceptual review" in Global governance: critical perspectives edited by Rorden Wilkinson and Steve Hughes. London: Routledge, 2002. pp. 94.
14 Hall, Rodney Bruce and Thomas J. Biersteker. "The emergence of private authority in the international system" in The emergence of Private Authority in Global Governance. Edited by Rodney Bruce Hall and Thomas J. Biersteker. Cambridge: Cambridge University Press, 2002. pp. 3.
15 Hall, Rodney Bruce and Thomas J. Biersteker. "The emergence of private authority in the international system" in The emergence of Private Authority in Global Governance. Edited by Rodney Bruce Hall and Thomas J. Biersteker. Cambridge: Cambridge University Press, 2002. pp. 3
8
Globalization also challenges the state-centric system of health governance.16 Through network actors, health goals have been redefined in terms of interests, and these interests, associated with the state, seek not only to survive but also to achieve viability and protection of what they deem to be their core public values. There are agreements on a range of formal and informal matters which support this argument. Others acknowledge the challenges, but suggest the focus should be on finding a better way to identify actors who should be taken as ‘authoritative.’ According to Friedman, being public, does not imply that a state or structure within must be involved, or be wielding authority.
THE POSTINTERNATIONAL MODEL
What follows, in other words, consists of theoretical claims rather than empirical proof. As such, it offers readers a choice: they can dismiss the delineation of a postinternational politics as absurd speculation, or they can allow for the possibility that the claims are sufficiently plausible to justify consideration as a basis for interpreting the course of events.17
As the above quote imply, the structures and processes depicted by this paradigm are still in the process of taking shape. However, "postinternational politics" is an appropriate marker for the changes taking place because it highlights the decline of long-standing patterns.18 Postinternational theory also represents a break with realism and neorealism in the analysis of politics. In this section, I address some foundational questions relating to postinternationalism.
16 Dodgson, Richard and Kelley Lee "Global health governance: a conceptual review" in Global governance: critical perspectives edited by Rorden Wilkinson and Steve Hughes. London: Routledge, 2002. pp. 97.
17 Rosenau, James N. Turbulence in world politics: a theory of change and continuity. Princeton: Princeton University Press, 1990. pp. 3.
18 Ferguson, Yale H. and Richard W. Mansbach. Remapping Global Politics: History’s Revenge and Future Shock. Cambridge: Cambridge University Press, 2004. pp. 18.
9
What are the sources of change for postinternational theorist?
According to Rosenau, the ever-growing interdependencies of economic, political and social life have been hastened and refined by five parametric transformations, as evidenced in India. The first source of change represents a shift from the largely industrial to postinternational order. As noted journalist T. Friedman recounts from a journey to India, globalization changed core economic concepts.19 He argues that the world is ‘flat,’ in the sense that globalization leveled the competitive playing fields between industrial and emerging market economies. Indian companies have become integral parts of a complex global supply chain for American-based corporations. This makes the "interdependence of people and events so much greater."20 A second source of change is evidenced in the emergence of world issues. For example, AIDS, TB, malaria and other environmental issues in India have been globalized, and are distinguished from traditional political issues by virtue of them being transnational rather than local in scope.21 A third dynamic is the reduced capacity of states and governments like India to provide satisfactory solutions to the major issues on their political agendas. For health, "authority does not necessarily have to be associated with government institutions."22 For example, the SARS epidemic highlighted both how easily new diseases spread and how effectively they can be identified and controlled by medical experts working in
19 Friedman, Thomas. The World is Flat: A brief history of the twenty-first century. New York: Farrar, Strauss, and Giroux, 2005.
20 Rosenau, James N. Turbulence in world politics: a theory of change and continuity. Princeton: Princeton University Press, 1990. pp. 12.
21 Rosenau, James N. Turbulence in world politics: a theory of change and continuity. Princeton: Princeton University Press, 1990. pp. 13.
22 Hall, Rodney Bruce and Thomas J. Biersteker. "The emergence of private authority in the international system" in The emergence of Private Authority in Global Governance. Edited by Rodney Bruce Hall and Thomas J. Biersteker. Cambridge: Cambridge University Press, 2002. pp. 5.
10
Fourth, with the weakening of whole systems, subsystems have acquired greater coherence and effectiveness, fostering tendencies towards decentralization. National health governance may now rely on informal mechanisms such as custom, common law, cultural norms, and values that are not legally formalized.Finally, Rosenau suggests there is a new feedback mechanism, which links actors to consequences. "With their analytic skills enlarged and their orientation toward authority more self-conscious,"groups, states, and other collectivities can demand social adjustments from either network or state actors. tandem with government and WHO.23 24 25
The postinternational model is then not based on a single-cause, static model. Rather, these sources of change are seen as responses to the upheavals that underlay the ever-growing independencies of economic, political and social life.
What theoretical tools should we use to approach the postinternational experience?
Theories are filtered through and colored by a kaleidoscope of preferences and perceived interests, expectations, normative commitments and personal experiences.26 The great realist and neorealist debates insist that network actors, as we have been discussing, are endogenous. However, non-realists envision a world where competition in the international arena is less fierce than on the domestic front; hence, institutions in maladapted states can survive for decades and centuries. This section goes beyond the theoretical and epistemological rationality of realist and non-realist arguments, and
23 Ferguson, Yale H. and Richard W. Mansbach. Remapping Global Politics: History’s Revenge and Future Shock. Cambridge: Cambridge University Press, 2004. pp. 280-81.
24 Dodgson, Richard and Kelley Lee "Global health governance: a conceptual review" in Global governance: critical perspectives edited by Rorden Wilkinson and Steve Hughes. London: Routledge, 2002. pp. 94.
25 Rosenau, James N. Turbulence in world politics: a theory of change and continuity. Princeton: Princeton University Press, 1990. pp. 13.
26 Ferguson, Yale H. and Richard W. Mansbach. Remapping Global Politics: History’s Revenge and Future Shock. Cambridge: Cambridge University Press, 2004. pp. 35.
11
instead considers constructivism, an alternative approach that offers meaningful explanations of postinternational politics.
The general constructivist is focused on the role of individuals as units of analysis in global politics.27 Constructivists emphasize that actors and their environments are mutually essential, and they are generally unwilling to separate actors from their environment even for analytic purposes.28 As R. B. Hall puts it, "changes in the collective identity of societal actors transform the interests of relevant collective actors." In addition, "group interests are strongly conditioned by the self-identifications of members of these groups with respect to other groupings."29 The degree of influence varies according to the context, and factors such as nature of polity, systemic distribution of capability and attitudes, and personality of leaders must also be considered.
Constructivists make a methodological bet that by focusing on the processes of socialization, in which agents and structures are mutually essential, they can explain important patterns and features of politics. At one extreme is Waltz’s parsimonious model in which the overall distribution of states’ power capabilities accounts for everything of importance. At the other end, scholars consider Gramsci’s endogenous position that everything is dependent on everything else. Intellectuals, Gramsci write, are the dominant group who exercise the subaltern functions of social hegemony and political government.30 This union of social forces serves as a ‘historic bloc,’31 which forms the
27 Ferguson, Yale H. and Richard W. Mansbach. Remapping Global Politics: History’s Revenge and Future Shock. Cambridge: Cambridge University Press, 2004. pp. 49.
28 Lake, David A. and Robert Powell, editors. Strategic Choice and International Relations. Princeton: Princeton University Press, 1999. pp. 32.
29 Ferguson, Yale H. and Richard W. Mansbach. Remapping Global Politics: History’s Revenge and Future Shock. Cambridge: Cambridge University Press, 2004. pp. 50.
30 Gramsci, Antonio. Selections from the prison notebooks edited and translated by Quintin Hoare and Geoffrey Nowell Smith. New York: International publishers, 1971. pp. 12.
12
basis of consent to social order, and which produces and reproduces the hegemony of the dominant class through a nexus of institutions, social relations and ideas.32
J. G. Ruggie and his colleagues33 offer another branch of constructivism, which accept the ‘subjective aspects’ of decision-making and the impact of actors’ behavior upon structures and trends. Constructivists of this mindset are especially interested in formal and less-formal international regimes and forms of governance.34 The argument here is that the actors that make up the system are themselves changing as they develop new conceptions of identity and political community. For example, the rise of nationalism in India significantly transformed the character and identity of people after independence. Similarly, new conceptions of identity and political community may result in different normative values at the local or national levels.
Not all constructivism is helpful for examining postinternational politics. For example, A. Wendt’s constructivism, while highlighting the role of ideas and perceptions in shaping behavior, shares the conservative realist school of state primacy. He writes: "It may be that nonstate actors are becoming more important than states as initiators of change, but system change ultimately happens through states."35 In this context, states are at the center of the international system, and ‘anarchy’ is still what states make of it.
31 Gramsci borrows the term ‘historic bloc’ from French philosopher George Sorel (1847-1922), who held that the only way for change to occur, was through the application of force. For example, a general strike can serve to enforce solidarity, class-consciousness, and ‘energize’ the working class.
32 Gramsci, Antonio. Selections from the prison notebooks edited and translated by Quintin Hoare and Geoffrey Nowell Smith. New York: International publishers, 1971. pp. 13.
33 This branch of constructivism emerges from the collective writings of Ruggie and his colleagues Nicholas Onuf and Fredrich Kratochwil. However, its origins are based on the works of Durkheim and Weber.
34 Keohane, Robert O. After Hegemony: Cooperation and Discord in the world political economy. Princeton: Princeton University press, 1984. pp. 78-80.
35 Ferguson, Yale H. and Richard W. Mansbach. Remapping Global Politics: History’s Revenge and Future Shock. Cambridge: Cambridge University Press, 2004. pp. 51.
13
For example, states that wish to survive are rational, in a sense that if you change the nature of states or their interactions, their ‘identities’ and ‘practice’ will change as well.36
The central preoccupations of the constructivist approach are what make it useful for postinternational analysis, and developing India’s social context. Core concepts acquire meaning through examining how people act, and that meaning evolves through this understanding of actions and belief. Constructivism gains explanatory power through its emphasis on identity and interest construction, and this allows for alternative explanations of global politics. For example, like liberals, constructivists also "insist on the importance of social processes that generate changes in normative beliefs, such as those prompted by the antislavery movement of the nineteenth century, the contemporary campaign for women’s rights as human rights, or nationalist propaganda."37 In addition, even though concrete advice can sometimes be hard to find, constructivism is particularly important for international relations theory as a mitigating factor for precipitant approaches put forward by the realist paradigm. Finally, constructivism ranges outside of paradigmatic boundaries, which enables it to prove that self-help and anarchy are not conditions that antecede international relations, but that are a creation – a construction.
Punjab, Orissa and West Bengal
Authority and power are closely related, however, authority in postinternational analysis is used to refer to institutionalized forms of expression of power.38 What
36 Wendt, Alexander. Anarchy is what states make of it: the social construction of power politics. International Organization, Volume 46, No. 2. (Spring 1992). Pp. 391-425.
37 Ferguson, Yale H. and Richard W. Mansbach. Remapping Global Politics: History’s Revenge and Future Shock. Cambridge: Cambridge University Press, 2004. pp. 51.
38 Rosenau, James. Turbulence in world politics: a theory of change and continuity. Princeton: Princeton University Press, 1990. pp. 11.
14
differentiates authority from power is the legitimacy of claims of authority. On the one hand, having legitimacy implies that there is some form of normative, un-coerced consent, or "the normative belief by an actor that a rule of institution ought to be obeyed."39 On the other hand, postinternational theorists make the argument that change is taking place within different frameworks of authority. "Self-interests have readily become equated to national interests, good citizenship to unthinking loyalty and automatic compliance with established authority."40 The experiences of Punjab, Orissa and West Bengal are especially interesting, as they provide insight into the possibilities and limitations of a particular strategy of change.
Punjab has the best infrastructure in India.41 Excluding agriculture, other major industries include manufacturing and tourism. However, rural development is the parameter of growth-oriented change. Traditionally rural areas have had limited access to infrastructural development, because cycles of poverty continues to haunt the countryside.42 District level rural development agencies have been established as nodal agencies for the implementation of centrally sponsored schemes especially anti-poverty programs per the guidelines of Government of India. The Center and the state government fund the schemes, which began as early as 1999. There is also a proliferation of anti-poverty initiatives in the rural regions, which raises the question of how and why are network actors emerging.
39 Hall, Rodney Bruce and Thomas J. Biersteker. "The emergence of private authority in the international system" in The emergence of Private Authority in Global Governance. Edited by Rodney Bruce Hall and Thomas J. Biersteker. Cambridge: Cambridge University Press, 2002. pp. 5.
40 Rosenau, James. Turbulence in world politics: a theory of change and continuity. Princeton: Princeton University Press, 1990. pp. 88.
41 www.india.gov.in
42 Government of Punjab – 11th Five Year Plan. www.punjabgov.nic.in PDF file, pp. 91
15
The role of multilateral actors in health governance is critically important for Orissa. As the state having the second lowest per capita income in the country, Orissa is part of an underdeveloped region. After independence, and in the absence of an industrialization program, the upper class (as in upper castes) was the first to take advantage of social and economic opportunities. At the same time, other groups struggled for subsistence and were never able to come up as competing forces. Today, the Department for International Development (DFID), UNICEF, and the World Bank heavily fund Orissa and are of great importance to the social and economic infrastructure. To address the emerging need of health, Orissa has encouraged new forms of actors. "There is a clear need to break through traditional boundaries within the government sectors, between governmental and non-governmental organizations and between public and private sectors."43
These arguments for social intervention are made in light of the fact that the standards of public services in India are abysmally low. The state is embracing the promotion of social concerns, because new authority structures effectively provide access to social services. India benefits Dreze writes, from "the universalization of basic entitlements to health care, elementary education and social security is perhaps the most significant social achievement of western ‘market economies’ in the twentieth century."44 It also follows that in postinternational politics the relevant actors are closely linked with the relevant networks, and are prone to cross the private-public divide by mobilizing
43 Government of Orissa: Report on Activities of Health and Family Welfare Department, Bhabaneswar- 2003-2004. Addendum – Private Partnership (PPP) in Health Sector, Scheme 1-Management of PHC, A Guideline. Pp. 1.
44 Dreze, Jean and Amartya Sen. India: Development and Participation. New York: Oxford University Press, 2002. pp. 43.
16
mass publics as well as elites on behalf of the values at stake.45 The collaborations embarked upon in Orissa, promote people oriented policies for the Government of Orissa, Department of Health and Family Welfare, and also, provide a platform to manage, implement, and promote preventive health services in the underserved and hard to reach community groups.46
West Bengal is unusual, and indeed one of the most unique states in the country. It is the only of the states in India to have been ruled continuously (since 1977) by a Left front government for more than a quarter of the century. This government has in turn been motivated by a vision of political, economic and social change that has been different from that observed amongst most other state governments or the central government.47 Moreover, this has resulted on a focus of two specific, but inter-related strategies at the state level: land reform, including both greater security of tenure to tenant cultivators and redistribution of vested land; and, decentralization and people’s participation through Panchayat institutions.
IMPLICATION OF STUDY
There are several crucial entry points through which an evaluation of new forms of governance can be made. The first lies in understanding why actors behave the way they do. An argument can be made that the behavior of actors is a consequence of widespread dissatisfaction with large-scale collectivities and the performance of existing authorities underscores the need to look for organizations that are more fully embracing.
45 Rosenau, James N. Distant Proximities: Dynamics beyond globalization. Princeton: Princeton University Press, 2003. pp. 398.
46 Government of Orissa: Report on Activities of Health and Family Welfare Department, Bhabaneswar- 2003-2004. Addendum – Private Partnership (PPP) in Health Sector, Scheme 1-Management of PHC, A Guideline. Pp. 1.
47 West Bengal Human Development Report, 2004. Online PDF file. Chapter 1, pp. 1.
17
Relevant here is the fact that the process of globalization has given citizens more access to information, which in turn has enabled them to join in collective actions that serve as avenues for expressing their discontent.48
Second, the state-centric world has undergone substantial expansion, and this has contributed to exponential increase in actors in the multi-centric world. According to Rosenau, the sheer number of movements has been a prime stimulus to the evolution of new loci of authority in the multi-centric world, and to the authority crisis that have wracked the state-centric world.49
Third, two level games also provide a way to evaluate politics. According to Putnam, state leaders in such games consider both the international and domestic audiences for their policies. They choose policy to satisfy both domestic and international conditions. The negotiation of treaties under the pressure of ratification is the common example of a two-level game. Negotiators must consider what treaties can be ratified when they negotiate. They do not have complete freedom to pursue their nation’s interests as they define it. Instead, they must keep an eye over their shoulder for what domestic groups will accept.50
From this point of departure, the implication of this study reaches beyond the 141 million Indians living in Punjab, West Bengal, and Orissa.51 Taken together, these states depict a world in which new authority structures either oppose or support the historically framed national structure. This study broadens the scope of analysis to account for
48 Rosenau, James D. and Mary Durfee. Thinking theory thoroughly: coherent approaches to an incoherent world, second. Oxford: Westview Press, 2000. pp. 62.
49 Rosenau, James D. and Mary Durfee. Thinking theory thoroughly: coherent approaches to an incoherent world, second. Oxford: Westview Press, 2000. pp. 62.
50 Putnam, Robert D. "Diplomacy and Domestic Politics: The Logic of Two-Level Games," International Organization, vol. 42, No. 3 (Summer 1988), pp. 427-60.
51 Data according to 2001 census: Punjab, 24 million; West Bengal 80 million; Orissa, 37 million. Total population for three states: 141 million.
18
among other key issues, shifting orientations that have been transforming national governance and health authority. The proliferation of new authority structures is epiphenomenal of elements of power relationships as described above however, new forms of governance also underscore the interconnectedness between economic development, public action and social progress.52 The dynamics of governance are intricate, and overlap several levels to form a singular, weblike process, which like a mobius neither begins nor culminates with the passage of a law or compliance with its regulations. The choices of many network actors determine outcomes in national politics because collectively, these arrangements deploy a form of authority whose effects are important for understanding not just the behavior of actors, but also for assessing the governance of states.53 As described by Wapner, "all of these actors devote themselves exclusively to setting up institutions to guide behavior with regard to public issues, thus clearly indicating the social function of governance."54 For Cox, these structures extend the range of stakeholders, diversify social goals, and produce greater complexity for the institutions where action takes place. This new perspective suggests authority structures govern by lending themselves both to the representations of diverse interests and to the universalization of policy.
52 Dreze, Jean and Amartya Sen. India: Development and participation. Oxford: Oxford University Press, 2002. pp. 83.
53 Cutler, Claire A. "Private international regimes and interfirm cooperation" in The Emergence of Private Authority in Global Governance by Rodney Bruce Hall and Thomas J. Biersteker (editors). Cambridge: Cambridge University press, 2002. pp. 23.
54 Wapner, Paul "Governance in global civil society" in Global Governance: Drawing Insights from the Environmental Experience. Oran Young (ed). MIT Press, p 80.
19
BIBLIOGRAPHY
Anand, Sudhir, Fabienne Peters and Amartya Sen (editors). Public Health, Ethics, and Equity. Oxford: Oxford University Press, 2006.
Berg, Bruce L. Qualitative Research Methods for the Social Sciences. Boston: Pearson Education, Inc., 2004.
Bhagwati, Jagdish N. and Padma Desai. India Planning for Industrialization:
Industrialization and Trade Policies Since 1951. London: Oxford University Press, 1970.
Bhagwati, Jagdish. Protectionism. Cambridge: The MIT Press, 1993.
Brass, Paul R. The Politics of India Since Independence, Second Edition. Cambridge: Cambridge University Press, 1990.
Braudel, Fernand. On History translated by Sarah Matthews. Chicago: University of Chicago Press, 1980.
Burchill, Scott et. al. Theories of International Relations, second edition. New York: Palgrave, 1996.
Carr, E.H. The Twenty Years’ Crisis 1919-1939: An introduction to the study of
international relations. New York: Palgrave, 2001.
Cassese, Antonia. International Law. New York: Oxford University Press, 2001.
Cerny, Philip G., "Power, Markets and Accountability: The Development of Multi-Level Governance in International Finance," forthcoming in Andrew Baker, David Hudson, and Richard Woodwards, eds., Finance and Multi-Level Governance.
Cerny, Philip G. "Globalization as Politics" in James Busumtwi-Sam and Laurent Dobuzinskis (eds.) Turbulence and New Directions in Global Political Economy. New York: Palgrave, 2003.
Cerny, Philip G. "Globalization and the Changing Logic of Collective Action" in Jeffrey A. Frieden and David A. Lake, ed., International Political Economy: Perspectives on Global Power and Wealth, 4th Edition. London: Routledge, 2000.
Chambliss, Daniel F. and Russell K. Schutt. Making Sense of the Social World: Methods of Investigation. London: Pine Forge Press, 2003.
Cox, Robert W. "Civil Society at the turn of the millennium: prospects for an alternative world order". Review of International Studies (1999), 25, 3-28.
20
Cox, Robert W and Tony Sinclair. Approaches to World Order. Cambridge: Cambridge University Press, 1996.
Cox, Robert W. and Michael G. Schechter. The Political Economy of a Plural World: Critical reflections on power, morals and civilization. London: Routledge, 2002.
Facts taken from speech made by Cristian C. Baeza, Acting Director of Health, Nutrition and Population, Human Development about his role at The World Bank (2006), www.wb.org
Cutler, Claire A. "Private regimes and interfirm cooperation" in Rodney Bruce Hall and Thomas J. Biersteker, eds. The Emergence of Private Authority in Global Governance. Cambridge: Cambridge University Press, 2002.
Devetak, Richard. "Critical Theory" in Theories of International Relations, second edition. Edited by Burchill, Scott et. al. New York: Palgrave, 1996.
Dreze, Jean and Amartya Sen. India: Development and Participation. New York: Oxford University Press, 2002.
Ferguson, Yale H. and Richard W. Mansbach. Remapping Global Politics: History’s revenge and future shock. Cambridge: Cambridge University Press, 2004.
Ferguson, Yale H. and Richard W. Mansbach. Polities: authority, identity and change.
Columbus: University of South Carolina Press, 1996.
Frankel, Francine R. and M.S. A. Rao (editors) Dominance and State Power in Modern India: Decline of a Social Order Volume II. Delhi: Oxford University Press, 1990.
Facts taken from speech made by Cristian C. Baeza, Acting Director of Health, Nutrition and Population, Human Development about his role at The World Bank (2006). www.wb.org
Frieden, Jeffrey A. and David A. Lake. International Political Economy: perspectives on global power and wealth, fourth edition. California: Thomson Wadsworth, 2000.
Germain, Randall D. "Reforming the international financial architecture: the new political agenda" in Global Governance: Critical perspectives edited by Rorden Wilkinson and Steve Hughes. London: Routledge, 2002.
Gill, Stephen (ed). Gramsci, Historical Materialism and international relations. Cambridge: Cambridge University Press, 1993.
Gill, Stephen and David Law. The Global Political Economy: perspectives, problems and policies. Baltimore: Johns Hopkins University Press, 1988.
21
Goldstein, Judith and Robert O. Keohane (editor). Ideas & Foreign Policy: beliefs, institutions and political change. Ithaca: Cornell University Press, 1993.
Gramsci, Antonio. Selections from the Prison Notebooks, edited and trans. By Quintin Hoare and Geoffrey Nowell Smith. New York: International Publishers, 1971.
Hall, Rodney Bruce and Thomas J. Biersteker (editors). The emergence of private authority in global governance. Cambridge: Cambridge University press, 2002.
Handelman, Howard. The Challenge of Third World Development, Second Edition. New Jersey: Prentice-Hall, Inc. 2000.
Healthy Cities and Urban Governance. World Health Organization. Updated 01 April, 2006. www.euro.who.int/healthy-cities.
Held, David., Anthony McGrew, David Goldblatt, and Jonathan Perraton. "The Territorial State and Global Politics," Chapter 1 in Global Transformations: Politics, Economics, and Culture. London: Polity, 1999.
Hobbes, Thomas. Leviathan. London: Penguin Books, 1981.
Human Development Report, 2004. "Introduction and Human Development Indices for West Bengal.
Human Development Report, 2007. www.undp.org
India Country Overview, 2007. The World Bank. (Uploaded 3/3/08) www.worldbank.org.in
India Inclusive Growth and Service Delivery: Building on India’s success Development Policy Review. Report No. 34580-IN. Published May 29, 2006.
India’s Tenth Five-Year Plan: 2002-2007. Summarized from Foreword written by Atal Bihari Vajpayee, Prime Minister of India, and Chairman, Planning Commission. (New Delhi, December 21, 2002)
Daniel Kaufman, Aart Kraay, Massimo Mastruzzi. "Governance Matters VI: Aggregate and Individual Governance Indicators, 1996-2006. (July 2007) World Bank Policy Research Working Paper No. 4280. Uploaded 3/4/08 from Social Science Research Network http://papers.ssrn.com/sol3/papers.cfm?abstract_id=999979#PaperDownload
Keohane, Robert O. After hegemony: cooperation and discord in the world political economy. Princeton: Princeton University Press, 2005.
Keohane, Robert O. Neorealism and its critics. New York: Columbia University press, 1986.
22
Kohli, Atul in Dominance and state power in modern India: decline of a social order. Francine R. Frankel and M.S.A. Rao (ed). Bombay: Oxford University Press, 1990.
Langhorne, Richard. The Coming of Globalization: Its Evolution and Contemporary Consequences. New York: Palgrave, 2001.
Lake, David A. and Robert Powell (editors). Strategic Choice and international relations. Princeton: Princeton University press, 1999.
Machiavelli, Niccolo. The Discourse edited with an introduction by Bernard Crick. London: Penguin, 1970.
Machiavelli. The Prince. London: Mentor Book, 1952.
Mearsheimer, John. Tragedy of Great Power Politics. New York: Norton, 2001.
Mill, John Stuart. On Liberty. Stillwell, KS: Digireads.com Publishing, 2005.
Milner, Helen V. Interests, Institutions and Information: domestic politics and international relations. Princeton: Princeton University Press, 1997.
Morrison, Ken. Marx, Durkheim, Weber: Formations of Modern Social Thought. London: Sage Publications, 1995.
Morgenthau, Hans. Politics Among Nations: The struggle for power, sixth edition. New York: McGraw-Hill Publishing Company, 1985.
Murphy, Craig N., "Global Governance: Poorly Done and Poorly Understood," International Affairs, Vol. 76, No. 4 (October 2000).
Oatley, Thomas. International political economy: interests and institutions in the global economy. New York: Pearson-Longman, 2004.
Paterson, Matthew. Understanding Global Environmental Politics: Domination, Accumulation, Resistance. New York: Palgrave, 2001.
Putnam, Robert D. "Diplomacy and Domestic Politics: The Logic of Two-Level Games," International Organization, vol. 42, No. 3 (Summer 1988), pp. 427-60.
Rosenau, James N and Mary Durfee. Thinking theory thoroughly: Coherent approaches to an incoherent world, second edition. Oxford: Westview Press, 2000.
Rosenau, James N. Turbulence in world politics: a theory of change and continuity. Princeton: Princeton University press, 19990.
23
Rosenau, James N. Distant Proximities: dynamics beyond globalization. Princeton: Princeton University Press, 2003.
Russett, Bruce and John Oneal. Triangulating Peace: Democracy, Interdependence and International Organizations. New York: W.W. Norton & Company, 2001.
Sinha, Aseema. The Regional Roots of Developmental Politics in India: A divided Leviathan. Bloomington: Indiana University Press, 2005.
Sørenson, Georg. The transformation of the state: Beyond the myth of retreat (Chapters 2,3,4). London: Palgrav, 2003.
Tucker, Robert C (ed). The Marx-Engels Reader, second edition. New York: W.W. Norton & Company, 1978.
Unnithan-Kumar, Maya (editor), Reproductive Medicine and the State: Cultural transformations in childbearing. New York: Berghahn Books, 2004.
Van Evera, Stephen. The Guide to Methods for Students of Political Science. Ithaca: Cornell University Press, 1997.
Wapner, Paul "Governance in global civil society" in Global Governance: Drawing Insights from the Environmental Experience. Oran Young (ed). MIT Press, 1997.
Wallace, Paul, and "Political Mobilization in Punjab," in Dominance and state power in modern India: decline of a social order. Francine R. Frankel and M.S.A. Rao (ed). Bombay: Oxford University Press, 1990.
Wallerstein, Immanuel. The Modern World System I: Capitalist agriculture and the origins of the European world economy in the sixteenth century. New York: Academic Press, 1974.
Weiss, Thomas et.al The United Nations and Changing World Politics, Third Edition. Colorado: West View Press, 2001.
Wilkinson, Rorden and Steve Hughes (ed). Global Governance: Critical perspectives edited by Rorden Wilkinson and Steve Hughes. London: Routledge, 2002.
World Bank Development Policy Review of India. www.worldbank.org
World Governance Assessment: Indicators for Assessing Governance. (Uploaded 3/4/08) http://www.odi.org.uk/WGA_Governance/Indicators.html
www.who.org Uploaded 3/3/08.
Young, Oran (ed), Global Governance: Drawing Insights From the Environmental Experience. Boston: MIT Press, 1997.
24
Young, Oran. Governance in World affairs. Ithaca: Cornell University Press, 1990.
25