Sara E. Davies Adam Kamradt-Scott, and Simon Rushton. Disease Diplomacy: International Norms and Global Health Security. (Baltimore: John Hopkins University Press, 2015), 179 pp.

Reviewed by: Samuel Adu-Gyamfi (Senior Lecturer, Department of History and Political Studies, Kwame Nkrumah University of Science and Technology)

Disease Diplomacy: International Norms and Global Health Security by Davies, Kamradt-Scott, and Rushton is a useful addition to scholarship on “disease diplomacy”. Prior to this book, different authors, like Philip D. Curtin who wrote Disease and Empire: The Health of European Troops in the Conquest of Africa (1998) show how European countries, especially the French, in an attempt to spread their imperialist quest, introduced and helped spread disease beyond borders with respect to the African continent. Mark Harrison in his Disease, Diplomacy and International Commerce: International Sanitary Regulation (2006) noted how the fear of the surge of infectious diseases prompted European states to adopt and develop international sanitary laws following the first International Sanitary Conference held in Paris in 1851. Gostin (2004) suggests that the improper functioning of the International Health Regulations (IHR) has prompted the WHO to modernize its methods since the latter’s inception in 1951. On the issue of disease and diplomacy, Fidler (2005) brings attention to how societies should govern their vulnerabilities to diseases that have generated international concern. Similarly, scholars like Aginam (2004), Baker and Fidler (2006), Fidler (1996; 1999; 2003) and Fidler et al. (1997) have raised arguments pertaining to how diseases are no longer of domestic essence alone but rather become urgent international concerns, especially in areas where health standards are low.

World Health Assembly. Photo credit: UN Photo/Eskinder Debebe

The knowledge gap that this book, Disease Diplomacy: International Norms and Global Health Security, seeks to fill is in the realm of the international norms and global security. The book seeks to achieve proper “disease diplomacy”. Authors’ efforts to provide answers were divided into five thematic chapters: “Building Global Health Security: The Drive for IHR Revision”; “From Tipping Point to Cascade: SARS and the IHR Revision Process”; “H5N1 in Asia: Tracking Government Behaviour”; “Swine Flu: The First Test of the IHR (2005)”; and, finally, “Post-H1N1: The IHR Review Process, State Capacity, and Political Will”.

The sub-structure of this book was derived from the “norm life cycle” theory (Finnemore and Sikkink 1998), which has been used to examine norm changes across a wide range of fields from Third World debt cancellation to the evolution of migration law as well as conflict resolution (p.13). The book captures the relationship between states under the obligations to report and to prevent the spread of disease across borders. It focuses on the authors’ understanding of the global health security regime, which is anchored in “social constructionism”. Social constructionists argue that the behaviour of states within international society is regulated by international norms, whether those norms are “soft” behavioral expectations or “hard” international law. (p. 10).

In the first chapter, the authors narrate the processes that culminated in the securitization of policy discussions around infectious disease. They emphasize that the last decades of the twentieth and the first decades of the twenty-first century saw a burgeoning policy and academic literature focused on diseases as a security issue. The authors argue that norm entrepreneurs are keen to capture the new security discourse to push for a reform of what would be known as the “global health security” regime (17). They highlight three stages of the major contributions of the norm entrepreneurs (the key norm entrepreneur is the WHO): firstly, they made a case for the revision of IHR; secondly, secretariat officials began to define the specifics of their new vision for disease diplomacy; and, finally, the secretariat made significant progress in refining and defining the shape of the norms that would eventually be encapsulated in the 2005 regulations  concerning the International Health Regulation (IHR) (p 18). As the authors argue, the WHO has not been a passive bystander; it has always attempted to juggle the priorities of members’ collective desires and its own health advocacy ambitions (p. 19). The authors conclude by stating that, in the years examined, there was a gradual formulation of new normative expectations through the early efforts of the norm entrepreneurs, especially secretariat officials, who promoted these norms to the states by attempting to “teach” them why they had a vital interest in a fundamental reform.

In the second chapter, the authors discuss the transition from norm tipping point to a norm cascade. The authors concentrate on the Severe Acute Respiratory Syndrome (SARS) outbreak of 2003 which created a sense of urgency that amplified the pre-existing security framing deployed by the WHO secretariat and helped to overcome earlier indifference and opposition. The authors emphasized that “given its rapid spread, high mortality rate and lack of known cure, this was a frightening wake-up call for governments, not least those in the developed world” (p.44). They argue that the adoption of the revised IHR in 2005 represented a formal acceptance by states of new behavioral expectations to which most of the states had already adhered without any formal requirement to do so. The authors ask a critical question; why was SARS such an effective trigger in mobilizing state support for the new norms of global health security, and by extension, the IHR revision process? They argue that SARS provided a stark illustration of a potential danger posed to states by a global failure to respond adequately to a rapidly transmissible disease outbreak. Notwithstanding this, the authors emphasize that it is not self-evident that the construction of infectious diseases as a national security issue would necessarily lead to inter-state cooperation. They emphasize that SARS served as a spark for a widespread acceptance of the new norms. It also increased awareness of the shortfalls in the existing IHR, and in the immediate aftermath a crucial turning point was reached (p. 47).

In the third chapter, the authors devote their attention to the avian influenza (H5N1) in Asia. The authors focus on the government’s behaviour. They argue that the H5N1 outbreak was a crucial chapter in the story of the changes to global health security regime. The authors discuss the early years of H5N1. They highlight the role of the Association of South East Asian Nations (ASEAN) in fostering a sense of duty to report and to put measures in place to contain the disease among its members. In return, the ASEAN emphasized that their members had a reasonable expectation that they would not be penalized for reporting and that in instances where trade restrictions were deemed necessary on scientific grounds, governments should seek international assistance as a quid pro quo for their cooperation (p. 79). The other sections of this chapter were devoted to states performance and reporting on H5N1. Ultimately, the authors argued that the H5N1 case illustrates that affected states readily accepted their responsibility in terms of transparent outbreak reporting, while the international community, led by the WHO and ASEAN, saw their members as having a clear role in promoting the advantages of new norms in global health security among others (p. 92).

In the fourth chapter, the authors discuss the Swine Flu (H1N1), which is regarded as the first test of the IHR (2005). They argue that despite the operationalization of the IHR in 2005, new norms of global security were in a norm cascade, where states were gradually being socialized to new norms. The authors infer that the H1N1 experience provided the first opportunity to clarify what exactly the norm is and what constitutes its violation. During the H1N1 norm cascade, the authors highlight the uncertainties about the applicability of the new norms, associated requirements, and reconciliation of international norms with existing domestic commitments, which is also referred to as norm localization.

In the fifth chapter, the authors devoted attention to the Post-H1N1 period. They examined the IHR review process, state capacity, and political will. Based on the findings of the IHR Review Committee, the authors concluded that new norms of global health security regime lay at the heart of the revised IHR in 2005. As an illustration, the final report of the IHR urged the WHO secretariat to undertake a variety of new activities to prevent the risk of future noncompliance with the norms of global health security. These activities included mobilization of international support to enhance the implementation of IHR’s core capacities; enhancement of information and communication capacities; acquisition of the public health rationale and relevant scientific information for travel and trade measures that exceeded WHO recommendations; and the encouragement of governments to ensure that the national IHR Focal Points (NFPs) were appropriately resourced to allow for prompt reporting and communication with the WHO (p.114).

General Assembly Discusses H1N1 Influenza. photo credit: UN Photo/Mark Garten.

The authors emphasized that a states’ agreement to a set of international regulations does not guarantee their compliance, as disincentives to report disease outbreaks have not been entirely overcome (p. 18). The authors outline reasons behind the apparent unwillingness and the struggle of countries to comply. The first one, which fed into the revision of the IHR, was the idea that globalization has brought about a paradigm shift; based on the argument that pathogens could no longer be contained within borders. Here, SARS became a timely illustration. Another set of examples include: the pandemic influenza, multi-drug resistant tuberculosis, and other antibiotic-resistant disease strains. The second reason is based on the argument that pathogens could be weaponized either by terrorists or through state-sponsored biological weapons programmes. Significantly, the issue of bioterrorism, as exemplified in persistent Anthrax attacks, which followed the 9/11 terrorist attack, triggered policy makers’ interests. The third rationale, which is not directly relevant to the core purpose of this book, includes the claims that high burdens of disease can have social, political, economic, and military effects that threaten the stability of states and regions (p. 21).

Finally, the book explores the background, drafting, adoption, and implementation of the revised IHR as an example of international disease diplomacy. It concludes that while the backlash against the WHO post-H1N1 was damaging, it also illustrates the extent to which countries continue to look up to the WHO for guidance when they are confronted by a cross-border disease outbreak. This book has presented a neat tapestry of disease diplomacy within the context of international norms and global health security. Its findings and recommendations are relevant to both academics and policy makers in this field.

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