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

GL OBA L H E A LT H
POL I T IC S
the oxford handbook of

GLOBAL
HEALTH
POLITICS
Edited by
COLIN MC INNES,
KELLEY LEE,
and
JEREMY YOUDE

1
 1
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Library of Congress Cataloging-in-Publication Data

Names: McInnes, Colin, editor. | Lee, Kelley, 1962– editor. | Youde, Jeremy
R., 1976– editor.
Title: The Oxford handbook of global health politics / edited by
Colin McInnes, Kelley Lee, and Jeremy Youde.
Other titles: Handbook of global health politics
Description: New York, NY : Oxford University Press, [2020] | Includes
bibliographical references and index.
Identifiers: LCCN 2019019778 | ISBN 9780190456818 (hardcover : alk. paper)
Subjects: | MESH: Global Health | Health Policy | International Cooperation
Classification: LCC RA441 | NLM WA 530.1 | DDC 362.1—dc23
LC record available at https://lccn.loc.gov/2019019778

1 3 5 7 9 8 6 4 2
Printed by Sheridan Books, Inc., United States of America.
 Contents

About the Editorsix

Contributorsxi
Foreword, by Peter Piotxiii

1. Global Health Politics: An Introduction 1

Colin McInnes, Kelley Lee, and Jeremy Youde

PA RT I F ROM I N T E R NAT IONA L

TO G L OBA L H E A LT H
2. The History of International Health: Medicine, Politics, and
Two Socio-Medical Perspectives, 1851 to 2000 19
Marcos Cueto
3. Globalisation and the Politics of Global Health 37
Matthew Sparke
4. The Politics of Global Health Inequalities: Approaches to
Studying the Role of Power 59
Yusra Ribhi Shawar and Jennifer Prah Ruger
5. Critical Approaches to Global Health 85
Alan Ingram

PA RT I I G L OBA L H E A LT H A N D
T H E W I DE R P OL IC Y AG E N DA
6. Global Health Diplomacy 103
Akram Khazatzadeh-Mahani, Arne Ruckert,
and Ronald Labonté
7. Security and Health 123
Simon Rushton
vi   contents

8. Global Health and Human Security 143

Robert L. Ostergard Jr. and Jeffrey A. Griffin
9. Critical Security Studies and Global Health 161
João Nunes
10. Biosecurity and the Risk to Global Health 179
Christian Enemark
11. Military Assistance during Health Emergencies 197
Adam Kamradt-Scott and Frank Smith
12. Global Health and International Development 217
Andrew Harmer and Jonathan Kennedy
13. The Politics of Gender and Global Health 237
Sarah Hawkes and Kent Buse

PA RT I I I G L OBA L H E A LT H G OV E R NA N C E
14. Global Health Governance 265
Colin McInnes
15. The State and Global Health 281
Ted Schrecker
16. Emerging Powers and Global Health Governance:
The Case of BRICS Countries 301
Yanzhong Huang
17. The Politics of Global Health Agenda Setting 325
Stephanie L. Smith and Jeremy Shiffman
18. The Politics of Intergovernmental Organizations in Global Health 347
Tine Hanrieder
19. Civil Society and Global Health Politics 367
David McCoy and Joseph Gafton
20. The Role of the Business Sector in Global Health Politics 387
Kelley Lee and Julia Smith
 contents   vii

21. Philanthropy and Global Health 409

Jeremy Youde
22. Trade and Investment Agreements and the
Global Politics of Health 427
Chris Holden and Benjamin Hawkins
23. The Global Politics of Healthcare Reform 445
Solomon Benatar, David Sanders, and Stephen Gill
24. Towards a Critical Political Economy of Global Health 469
Ted Schrecker

PA RT I V I S SU E S I N G L OBA L
H E A LT H P OL I T IC S
25. The Human Right to Health and Global Health Politics 493
Gorik Ooms and Rachel Hammonds
26. Reporting Disease Outbreaks in a World with
No Digital Borders 513
Sara E. Davies
27. The Politics of Pandemic Influenza Preparedness 531
Adam Kamradt-Scott
28. The Global Politics of HIV and AIDS 551
Alan Whiteside
29. The Global Politics of Neglected Tropical Diseases 569
Obijiofor Aginam
30. The Politics of Global Vaccination Policies 583
Stuart Blume
31. The Global Politics of Access to Medicines: From 1.0 to 2.0 605
Suerie Moon and Ellen ‘t Hoen
32. Non-Communicable Diseases and Global Health Politics 627
Roger Magnusson
viii   contents

33. The Politics of Global Tobacco Control 661

Kelley Lee
34. The Politics of Global Bioethical Frameworks 685
Diego S. Silva and Jeremy Snyder

Index 699
 About the Editors

Colin McInnes is professor of international politics in the Department of International

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

Obijiofor Aginam, United Nations University

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

David McCoy, Queen Mary University of London

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

Peter Piot

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

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

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

Gl oba l H e a lth
Politics
An Introduction

Colin M c Innes, Kelley Lee,

and Jeremy Youde

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

health politics. These include globalisation and health (Hanefeld 2015; Lee 2003); the
relationships between global health and foreign policy, security, and development
(Davies 2019 Price-Smith 2010; Youde and Rushton 2014; global health governance
(Harman 2012; McInnes et al. 2014; McInnes and Lee 2015; Youde 2012; Kickbusch
2005); the global political economy of health (Schrecker and Bambra 2015); and policy
debates focused on specific issues such as HIV and AIDS (Anderson and Patterson
2017 Dionne 2018), pandemic influenza (Kamradt-Scott and Lee 2011), tobacco control
(Lee and Hawkins 2016), access to medicines (Roemer-Mahler 2014), health inequities
(Ruckert and Labonte 2017; Benatar 2016), mental health (Howell 2011), Ebola
(Gronke 2015), biosecurity (Enemark 2017; Osterholm and Olshaker 2017), legal and
ethical frameworks (Poku and Sundewall 2018; Ruger 2012), and non-communicable
diseases (Reubi et al. 2016). Even more tellingly, the field is now engaging in critical
examinations of itself (Brown, Craddock, and Ingram 2012; McInnes and Lee 2012;
Davies et al. 2014).
The dynamism of global health politics as a field makes this an important time to
­publish a Handbook that brings together the current state of this scholarship. At the
same time, this dynamism necessarily colours its current construction. This Handbook
captures a particular moment in this field’s development when it is beginning to dem-
onstrate signs of maturity and its boundaries and constituent elements are formative.
We thus do not want to suggest that the field is fixed. Indeed, the range of issues consti-
tuting the field of global health is far from settled. When we began this venture, the
2014–2016 outbreak of Ebola virus in West Africa was waning, the Zika virus crisis was
beginning, the Rockefeller-Lancet Commission on Planetary Health (see ‘Safeguarding
Human Health’ 2015) had just commenced its work, and the UN General Assembly’s
High Level Meeting on antimicrobial resistance had yet to take place. We have little
doubt that the political agenda in global health will continually change and be reshaped
by new challenges that emerge. At the same time, scholarly debates within subfields,
including over the nature and extent of the field, remain far from settled. Major works
were published whilst this Handbook was being prepared (e.g., Davies 2019; Dionne
2018; Patterson 2018) and will continue to appear after its publication. There are also
important debates emerging about the need to decolonise global health as a field of
study and practise: To what extent does existing scholarship too blithely sustain, repli-
cate, and even exacerbate existing power differentials within the global system (Biehl
2016; Birn 2014; Waitzkin 2015)? An orthodoxy is emerging over the focus areas of the
field and, like all orthodoxies, it is generating its discontents, who are pushing at the
boundaries and critiquing the nature of the field (see, e.g., Birn, Pillay, and Hotz 2017).
This dynamic and formative scholarship is what this Handbook attempts to capture
and articulate in its present form. This volume is intended as both an assessment of the
state of the field and, we hope, a distinct contribution to advancing that field. The latter
ambition, in turn, comprises two elements, presenting an understanding of what the field
is, together with its major subfields and critical perspectives, at a point of immanent
maturity, and how individual essays further understanding of issues comprising the
field and its subfields.
 Global Health Politics: An Introduction   3

The Meanings of Global

Health and Global
Health Politics

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

ethnicity)’ (Krumeich and Meershoek 2014). Global health actors include the state, but
also encompass

• international (state-to-state or intergovernmental) organisations (such as the

World Health Organization [WHO] and the World Bank),
• private for-profit entities (such as corporations),
• public-private partnerships (such as the GAVI Alliance),
• civil society organisations (such as the International AIDS Society and Médicins
sans Frontières),
• charitable organisations and foundations (such as the Rockefeller Foundation,
Rotary International, and the Wellcome Trust), and
• individuals wielding normative or material power (such as Bill and Melinda Gates,
Michael Bloomberg, and Mark Zuckerberg).

Importantly, global health politics is intimately concerned with power in at least two
dimensions. First, power is distributed amongst and exercised by global health actors (or
agents), but is also embedded within global health structures. The ways in which global
health actors (i.e., actors with recognised roles and/or interests in global health) interact
within a so-called global health architecture is shaped by their relative power. At the same
time, these interactions take place within structures that enable or disable the exercise of
that power. Second, power is both material (the distribution of and capacity to access and
use resources such as financial and human capital and technology)—and ideational (the
distribution of and capacity to access and use ideas in ways that persuade others of the
cognitive validity of their worldview) (Carstensen and Schmidt 2016). Ideas shape what
are deemed priority needs, agreed policy solutions, or legitimate norms to be pursued in
global health. Ideas structure global health by delineating not simply what is desirable but
what is possible. For example, the idea of globalisation enables initiatives for the global
surveillance of communicable diseases, the idea of health as a human right legitimates
the involvement of civil society actors in global heath discussions, and the idea of
humanitarianism underpins development aid. But ideas also provide competing
understandings about global health within which agents operate. Thus, from the per-
spective of a right to health, access to medicines is highly desirable, but from a position of
international trade, incentivising research and development via patent protection is vital
even if it limits affordability by keeping prices higher. In this sense, both material and
ideational power interact together to shape the politics of ‘who gets what’ in global health.

The Development of Global

Health Politics

Global health politics as a field of scholarly inquiry has emerged as a result of not only
the discursive shift to ‘global health’, but also the changed political landscape. During the
 Global Health Politics: An Introduction   5

twentieth century the dominant discourse presented health primarily as an issue of

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

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

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

The Structure of the Handbook

The study of global health is located at the intersection of several academic subjects and
disciplines. At its heart are the biomedical sciences and public health, given their efforts
to understand, develop, and implement effective measures to protect and promote
population health amid globalisation. The field of global health politics involves a simi-
larly multi- and interdisciplinary breadth, including

• political science and especially international relations (given its interest in power,
security, rights, and governance at the international and global levels),
• development studies (given the marked rise of health development aid since the
1990s),
• economics (given the importance attributed to healthy populations for economic
growth and prosperity),
• anthropology (given the variety of understandings of health and disease around
the world and the challenges of external actors providing health services in com-
munities), and
• public administration (given efforts to strengthen and reform the performance of
global health institutions).

At the heart of this, however, are the disciplines of politics and, especially, inter-
national relations. The study of both politics and international relations dates back over
centuries, and the disciplines have developed sophisticated methods and ideas, contro-
versies, and insights into the workings of power; how decisions are made; questions of
rights and responsibilities; and understanding who gets what, how, and why at multiple
8   COLIN McINNES, KELLEY LEE, AND JEREMY YOUDE

levels of analysis (i.e., to employ a perhaps overused phrase, ‘from the local to the global’).
These are precisely the concerns of global health politics, and it is therefore entirely
appropriate that these disciplines, politics and international relations, and their ideas
should provide a core of knowledge and understanding to the field. Works on global
health politics do not always demonstrate this underpinning awareness of the disciplin-
ary expertise in political science and international relations (Paxton and Youde 2018).
Nevertheless, an understanding of the nature of politics and the workings of power
appears to us to be fundamental to the study of global health politics. But equally the
field cannot be limited to this; to use Kenneth Waltz’s well-known aphorism, it is neces-
sary but not sufficient. Rather, the field requires knowledge and techniques from a var-
iety of disciplines, which intersect to produce a more complete understanding of global
health politics than any one discipline can provide. The result of this intersection is a
field that is inherently both multi- and interdisciplinary. It is also characterised by meth-
odological pluralism and varied theoretical perspectives: from positivism and empirical
studies, to critical theory and social constructivism.
This Handbook seeks to capture both the benefits of and complications arising from
this intellectual diversity. We have organised the Handbook into five sections. The first
(this chapter) outlines our understanding of the field and reflects on its development at a
particular moment. The second section charts the shift from international to global
health and introduces two themes that are central to the study of global health politics as
a whole. The first is that of power. The determinants and outcomes of global health are
not equal, nor is the manner in which issues are constructed and solutions articulated.
The nature of global health is intrinsically political, reflecting power relations which
play a significant role in whether various groups can set the political agenda and/or
claim resources. Second, we introduce ideas of critical thought, which are then pursued
in more detailed chapters elsewhere in the volume. This is important both to the
Handbook and to the field in problematising what are seen as ‘givens’, in asking ques-
tions about the perceived nature of the material world, and in opening up a space for
different ways of seeing the world of global health. For us, this is a part of global health
politics not in the Kantian sense of critique—that global health politics is about the
application of reason and the use of rationality to solve problems—but, as Alan Ingram
states ‘to approach global health critically is to appreciate that any analysis of global
health takes place in the midst of power relations, power struggles and political events’
(see Ingram, this volume). Not least, thinking critically challenges the manner in which
power structures establish what is considered acceptable. It suggests that ‘common sense’
is not an objective assessment of an independent material world, but rather a construction
‘for someone and for some purpose’, to use Robert Cox’s famous trope (Cox 1981, 128).
The third section examines the politics of how global health has influenced, been
affected by, and sometimes become part of other policy arenas. Indeed, one of the tensions
in global health politics is whether linkage to these other policy arenas—such as inter-
national development and security—provides additional leverage for global health,
allowing it to become more prominent on political agendas, or means that health is
 Global Health Politics: An Introduction   9

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

Pondering the Future(s) of

Global Health Politics

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

Action Plan (Global Fund to Fight AIDS, Tuberculosis, and Malaria, Office of the
Inspector General 2017). A blunt independent investigation in 2018 of harassment
and bullying by UNAIDS senior officials has raised broader questions about the
appropriateness of a disease-specific initiative (UNAIDS Programme Coordinating
Board 2018). Which institutions will emerge as the key players in global health governance
in the coming years?
Third, the broader context within which global health politics occurs is changing in
several potentially significant ways. China’s continued political and economic rise may
challenge long-standing distributions of power in global health. The creation of the
Asian Infrastructure Investment Bank in 2016 represents a new multilateral develop-
ment financial institution that could compete with the World Bank and International
Monetary Fund (Dahir 2018). As China has assumed a more prominent global role, it
has also shown an interest in global health governance, though it has tended to prioritise
its own bilateral initiatives over existing institutions (Chan 2011). Furthermore, the
success of populist movements around the world—from Donald Trump’s successful
presidential campaign in the United States, to Brexit in the UK, to the election of far-
right politician Jair Bolsonaro to the presidency of Brazil, to the significant increase in
support for far-right Eurosceptic parties across Europe—suggests the emergence of a
strong constituency disillusioned with the effects of globalisation. The very countries
that have played such important roles in creating and sustaining global health govern-
ance institutions and laying the foundations for the successes achieved so far are now
openly questioning the usefulness of these organisations, and of multilateralism and
globalisation in general. This is not to say that we are witnessing the end of globalisation,
but that it has reached a new phase that includes potential changes to the structures,
norms, and funding systems that have supported global health governance thus far.
When global health politics started to come into its own as a field, globalisation was the
dominant geopolitical narrative. Recent political changes now hint that this agenda is
more contested.
Fourth, if the narrative of globalisation is being questioned from a resurgent national-
ism, then equally it is being taken in new directions with the emergence of a ‘planetary’
agenda. If globalisation focused on the increased speed and intensity of human inter-
actions on a global scale, ‘planetary politics’ firmly places animal and environmental
factors in the mix. For some, such as the Rockefeller Foundation-Lancet Commission
on Planetary Health, this is largely about how global environmental developments (par-
ticularly related to climate change and the food chain) will affect human development
and health (Horton et al. 2014; ‘Safeguarding Human Health’ 2015). For others, it is a
much more radical reimagining of the political (e.g., Burke et al. 2016). For health, this is
seen in the ‘One Health’ agenda, in which the politics surrounding animal welfare and
the environment are integral elements to understanding global health.
Fifth, the field of global health politics is presently largely characterised by a mix of
multi- and interdisciplinary work. As is evident in this volume, some chapters can be
readily accommodated within single disciplinary perspectives. Others, despite draw-
ing on elements from several disciplines, are clearly ‘majoring’ in one; some—probably
the minority—are fundamentally interdisciplinary. That the field is so inherently open
 Global Health Politics: An Introduction   11

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

Conclusion: Politics and

Global Health

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

Note
1. On these developments, see, for example, McInnes and Lee (2012); Davies (2010); and
Youde (2012).
12   COLIN McINNES, KELLEY LEE, AND JEREMY YOUDE

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 PA RT I

F ROM
I N T E R NAT IONA L
TO GL OBA L
H E A LT H
 chapter 2

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

Marcos Cueto

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

From International Agreements to

Specialised Institutions

Pandemics—epidemics that affect several countries simultaneously—massive migra-

tion, and the expansion of maritime commerce, especially with colonial ports, stimu-
lated the first coordinated governmental decisions on international health. That was the
case with cholera, the most important pandemic of the nineteenth century. The disease,
which could be easily identified by the violent diarrhoea and other dramatic symptoms
that it produced, was new to Europe and was presumed to have come from India (where
it was endemic) by means of steamships. From 1851 onward, governments, mainly of
Western Europe and the United States, organised a series of International Sanitary
Conferences (eleven by 1913). Initially the objectives of these conferences were to
improve and regulate quarantines and standardise compulsory isolation measures for
passengers suspected of having cholera (Howard-Jones 1975; Stern and Merkel 2004).
They made progress in overcoming the ambiguous, erratic, and controversial maritime
quarantine practises, land controls, and compulsory isolation hospitals of the turn of
the nineteenth century and facilitating national consensus amongst merchants, diplo-
mats, and health leaders. The agenda of these meetings was set by the imperial European
powers and the priorities of European tropical medicine regarding the protection of
industrialised nations from diseases coming from abroad, the protection of colonisers,
the improvement of colonial economies, and the construction of an image of ‘humani-
tarianism’ to validate the colonial enterprise. It was also important to establish outposts
in Africa, Asia, and other tropical regions of the world as medical research enclaves that
would produce results to be published in the metropolis and enhance the scientific pres-
tige of Western medicine.
Some success occurred in articulating maritime sanitation with the economic inter-
ests of merchants, who used to reject any sanitary control of goods and passengers
(Hardy 1993), although the confrontation of stigma and discrimination—which usually
blamed foreigners and the poor for epidemics—received less attention. However, effect-
ive decisions were made slowly because there was no agreement on what to do. Initially,
the first sanitary conferences achieved little consensus because of disagreements
between diplomats and physicians and debates amongst medical doctors. For example, it
took some time for many representatives at the conferences to accept the findings of
British doctor John Snow, who since 1850 had argued that cholera could spread in cities
in water contaminated with faeces of sick people (meaning that safe water and sewage
systems were the most effective control measures). Instead, many physicians argued that
the disease was not transmitted by direct exposure but had a miasmatic origin in gar-
bage and filth and could be addressed only with local hygiene.
International health experts’ attention was not solely focused on cholera, however. In
1871 a yellow fever epidemic killed thousands of people in Buenos Aires, Argentina,
proving that the illness was not limited to the Caribbean—as previously believed—and
 History of International Health   21

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

humanitarian International Federation of Red Cross Societies has been responsible for
bringing together voluntary work, whilst in Geneva the League of Nations established its
own health body (the League of Nations Health Organization [LNHO]). Despite the fact
that the United States chose not to join the League of Nations because of its isolationist
policies during this period, US health authorities were part of both the LNHO and the
OIHP (Borowy 2009a).
Because of hostilities between member countries of the two agencies, it was not pos-
sible to merge the LNHO and the OIHP. (France, for example, was a defender of the
OIHP but did not agree with the LNHO.) However, the leader of the LNHO, Ludwik J.
Rajchman, was a Polish doctor who became a champion in addressing the international
spread of disease by research, by helping the investigation to standardise drugs and
treatments, and by the promotion of improved life conditions for poor people around
the world (Balìnska 1995). This perspective was part of a European tradition known as
social medicine, which can be traced to the nineteenth century, but only in the twentieth
century was it institutionalised in professorial chairs, institutes, and academic journals.
Rajchman and other staff at the LNHO sought to promote the view of medical and social
reform outside Western Europe, including in China, Bolivia, and Greece (Borowy 2009b).
In 1937 the LNHO organised a landmark conference on rural hygiene in Bandung,
Indonesia—after a proposal made by India and China—that influenced social medicine
and intersectoral perspectives on the health of peasants, who made up the vast majority
of the populations of low-income countries (LICs) (Brown and Fee 2008). In the years
before World War II, however, Rajchman had to abandon the League of Nations, as the
LNHO’s director followed a policy of appeasement of Nazi Germany and was con-
sidered a political ‘radical’. In addition to this, the League of Nations’ capacity for action
was limited; although there was much hope invested in the institution, it did not have
the political weight to impose its decisions and did little to oppose the Nazi invasion of
Czechoslovakia in 1938 and of Poland in 1939. In the interwar period from 1919 to 1939,
therefore, the two official agencies of international heath had little authority and lacked
legitimacy. Rajchman´s departure was a clear example of how in critical times politics
took precedence over medical priorities in international health.
Another important organisation in this period was the Rockefeller Foundation, a
philanthropic body founded in New York in 1913 (Barona Villar 2016). The foundation
interacted with the schools of tropical medicine in Europe, especially the London and
Liverpool schools in the United Kingdom, whose leaders had from their founding at the
turn of the twentieth century an international—and more precisely colonial—scope and
perspective. Scientific races to establish the origins and the means of transmission of the
major infectious diseases that hit colonial people were part of the global narratives of
both the foundation and tropical medicine in the United Kingdom and other European
countries. Frequently, members of the foundation, of schools of tropical medicine,
international agencies, and supporters of social medicine attended the same meetings,
published in specialist journals, and worked in medical programmes in colonial and
postcolonial societies, thus creating a network of expert knowledge in international
health that reflected and established power relations (Neill 2012).
 History of International Health   23

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

Enter the World

Health Organization

The new international UN agency for health, WHO, was founded in Geneva in 1948 and
replaced the other European agencies (the OIHP and the LNHO), but it made an agree-
ment with PAHO to be its regional representative in the Americas. WHO was created
with a visionary perspective laid out in the founding document as part of the preamble
to its 1948 constitution and is an example of the second, holistic perspective on health-
care. It affirms that health not only consists of the absence of illness but is a fundamental
human right and an obligation of states (Cueto, Brown, and Fee 2011).
The first director-general of WHO was the Canadian psychiatrist Brock Chisholm,
who remained in the position from 1948 to 1953 (Farley 2008). During this period WHO
established regional offices in Southeast Asia, Europe, the Eastern Mediterranean, the
Western Pacific, and in sub-Saharan Africa (the latter only after some resistance from
the imperialist nations France, Belgium, Portugal, and Britain). In regions that com-
prised a significant number of LICs, such as South Asia and Africa, WHO experienced
in the early years an ongoing tension between centralisation and uniformity of response,
according to the desires of the Geneva headquarters, and more regional power and sen-
sitivity to local needs, which member countries pressed for. WHO assumed a number of
roles, including reconstructing old health systems for prevention and treatment in
European countries where they had been destroyed, as well as creating new ones in
other countries where they had not previously existed, and creating a system for collect-
ing epidemiological information.
After its establishment in 1948, WHO had to work against the backdrop of the Cold
War and the political rivalry between the United States and Soviet Union. The capitalist
countries sought to contain Soviet expansion into new parts of the world, whilst the
Moscow government intensified efforts to intervene in the internal politics of countries
that were politically significant on account of their location. The result was a hardening
of relations between the two superpowers. A precursor to these Cold War tensions
became manifest in WHO when the Soviet Union left the agency between 1949 and 1956.
The official reason given was its dissatisfaction with the work carried out by the UN and
WHO. Nevertheless, the underlying reason was that the Soviets and the Americans had
opposite visions of public health. The Soviets believed in a direct relationship between
social and health problems. They attributed the underlying causes behind illnesses to
the precarious working conditions of the population at large and to capitalist exploitation.
In the Soviet Union private medical practice was prohibited, and health services were
nationalised (as was the case with a number of sectors of the economy), whilst in the
United States a mixed model involving private and public sector doctors and the
supremacy of a network of private hospitals prevailed.
In July 1955 the Soviet Union chose to return to WHO, a decision influenced by the
death in 1953 of Joseph Stalin, the hard-line communist leader. The new Soviet leader,
 History of International Health   25

Nikita Khrushchev, guided by the goals of ‘peaceful coexistence’ and de-Stalinisation,

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

agency because it generally held the majority of votes in the governing health assemblies
and had well-funded bilateral international health agencies. Therefore, the US govern-
ment retained an important degree of independence in international health matters.
Although the US State Department had had health cooperation organs since the 1940s,
the most important was not established until 1961 as a unit within the US Agency for
International Development (USAID). Shortly thereafter, other industrialised countries
created and relied more on their own bilateral agencies, which in time concentrated
more human and financial resources than multilateral agencies. The creation of these
bilateral agencies made technical assistance and international health programmes an
intrinsic dimension of the foreign policies of donor nations. Again, medicine and politics
appeared in a new combination—which favoured the latter—in the history of inter-
national health.
Candau was re-elected director-general of WHO in 1958, 1963 and 1968, and stayed in
the post until 1973. In the 1950s and early 1960s, the most important global health pro-
grammes were the so-called vertical campaigns, which were clear examples of the first,
technocratic perspective on international health. They generally involved actions that
sought to eradicate a specific infectious disease by means of certain technologies, along-
side complex administrative and financial operations. In addition, these campaigns had
advantages for some HICs. In terms of national security, it was a means to protect their
own territory against diseases coming from abroad. Another reason was the interest in
global economic productivity: at the start of the 1950s, the United States and other
industrialised nations had investments spread across the globe and were concerned
about protecting the consumption of their products. The campaigns were also them-
selves a form of indirect subsidy to some US industries, since guidelines were laid down
for the procurement of US medication and medical technology. A prominent example of
this was the then widely promoted insecticide dichlorodiphenyltrichloroethane (DDT),
used to control mosquitos that carried malaria. DDT was largely produced in the United
States by oil companies that had found an important opportunity to sell insecticides in
the malaria eradication campaign.
WHO’s most important vertical campaign was carried out to address a typically
rural disease: malaria, characterised by intermittent fevers that are generally not fatal
but reduce the capacity for work and have a negative impact on agriculture and busi-
ness. This was a clear example of the first perspective described at the beginning of this
chapter—reliance on medical technology that validated international health as a con-
tribution to global economic growth—because the justification for the elimination of
malaria portrayed it as an ‘economic’ disease. In other words, disease eradication was a
socio-medical intervention for the improvement of nations’ and the world’s economies.
The means used were technological in the form of insecticides (DDT) and medication.
In spite of some doubts about these—some reports warned of DDT not being sufficiently
effective against mosquitoes, whilst medication did not always eliminate the infectious
agent, Plasmodium falciparum—the 8th World Health Assembly held in Mexico in 1955
approved the eradication of malaria (Cueto 2007b). National autonomous programmes
were established in almost all countries in the world. The determination to eliminate
 History of International Health   27

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

of the first international health perspective). One of the political justifications for
implementing family planning was the fear that poor and overpopulated countries
would be influenced by communism because their lack of infrastructure made provid-
ing food and jobs for an increasing number of people difficult. In this political context,
LICs put into practice programmes aimed at limiting the growth of their populations,
generally targeting poor women (a notable exception being India, which prioritised
male sterilisation, frequently poor males, through vasectomy).
At this time, Catholic country members of WHO did not consider population
growth to be a problem and retained nationalist pro-birth policies. The Soviet Union
and most communist countries—with the exception of China—viewed the concerns
about overpopulation as a pretext by capitalist countries to obstruct the potential rise
of future revolutionaries. These opponents of family planning were convinced that
LICs needed more inhabitants in order to increase their economic and military poten-
tial. As an indication of the lack of consensus in WHO based on political considerations
of member states, some WHO directives were against abortion, whilst others supported
it along with family planning. However, those bilateral agencies and private sector
organisations that supported birth control never had much confidence in the capacity
of WHO to lead an international programme for family planning. Thus, in 1969 the
United Nations Population Fund (UNFPA) was created, managed by the United
Nations Development Programme (UNDP). In 1972, in recognition of the reach of its
operations, UNFPA was placed under the responsibility of the United Nations
General Assembly and given the same status as UNDP and UNICEF, a decision that
created jurisdictional problems with WHO.
In the 1970s WHO gave in to pressure from population control programmes of the
bilateral agencies and philanthropic organisations. A factor that contributed to this
change was the fact that the Soviet Union had changed its traditional pronatality pol-
icies to reduce the number of illegal abortions carried out in the country. In the early
1970s WHO set up the Special Programme of Research, Development and Research
Training in Human Reproduction. However, the political landscape that supported
these programmes changed once again in the 1980s, not least with the arrival of con-
servative governments in the United States and Europe and the rising significance of
human rights and feminist groups. These groups denounced the gender, racial, and
social bias of these vertical family planning programmes aimed at controlling the lives
of women and the poor. They harshly criticised compulsory sterilisation in India,
China, and other LICs. The Indian government offered financial compensation to
individuals who underwent sterilisation, whilst the Chinese birth control programme
(which promoted abortion and only allowed couples to have one child) also came
under attack. Conservatives joined the criticism, questioning whether reducing popula-
tion growth actually contributed to economic growth in poor nations. Consequently,
US foreign policy towards population control changed dramatically, with Presidents
Ronald Reagan and George H. W. Bush suspending support for family planning by
international agencies. A turning point was Mexico City´s International Conference
on Population in 1984, where the United States announced that recipients of bilateral
aid had to agree, as a condition of receiving assistance, to neither perform, discuss,
 History of International Health   29

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

The Vicissitudes of Primary

Healthcare

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

idea that the good health of industrialised countries was the result of an increase in the
number of doctors who had graduated from universities. Third, PHC was inspired by
the popularity of ‘barefoot’ rural doctors in communist China, who were part of groups
of health workers who lived in the communities that they served. These doctors placed
greater importance on rural outreach than on urban care, carried out preventative activ-
ities, and mixed Western medicine with traditional Chinese medicine. Finally, during the
early 1970s some agencies—mainly UNICEF, the UN International Labour Organization,
and USAID—de-emphasised technical assistance programmes and adopted a ‘basic
human needs’ approach, which prioritised integral programmes in nutrition, family
planning, development of health infrastructure, and basic education in shantytowns
and rural areas. These influences were important to a number of public health leaders,
including the charismatic Danish doctor Halfdan Mahler, who was elected director
general of WHO in 1973 (and subsequently re-elected twice, holding the post until 1988)
and was a staunch supporter of PHC.
The most important event for PHC was the International Conference on Primary
Health Care, organised by WHO and UNICEF in September 1978 in Alma-Ata (now
Almaty), then the capital of the Kazakh Soviet Socialist Republic (Cueto 2004). The con-
ference’s final declaration included an ambitious goal: ‘Health for all by the year 2000’.
The declaration contained a criticism of hospitals and overspecialised medical teams
that were deemed too expensive, too sophisticated, or irrelevant for the necessities of
poor people. In contrast, an ‘appropriate’ technology—meaning affordable, sustainable
and directed to treating and preventing common diseases—was the alternative to meet
poor people’s needs. At the same time, the installation of health posts in rural areas was
prioritised over the construction of specialised hospitals. Finally, the declaration associ-
ated good health systems with social development, and work in healthcare was con-
ceived as part of broader attempts to improve people’s life conditions. PHC was therefore
positioned at the centre of the health system, and in a number of articles Mahler
defended the idea that health should be an instrument of development and not simply a
by-product of economic progress (Litsios 2008).
One year after the PHC meeting in Alma-Ata, a new concept arose: selective pri-
mary healthcare (SPHC). Supporters of this new idea considered the Alma-Ata
Declaration to be too idealistic because of its ambitious timeline and vague target of
health for all by the year 2000. Instead, in 1979 the Rockefeller Foundation, leaders
from bilateral agencies, and UNICEF began to work on identifying specific interven-
tions for infant illnesses, including diarrhoea and malnutrition. Although the content
and interventions of SPHC were not clear at first, in subsequent years (particularly in
the first half of the 1980s) these were encapsulated in the acronym GOBI: growth
monitoring, oral rehydration, breastfeeding, and immunisation. The first intervention
was focused on identifying children who did not grow in line with the ideal height and
weight for their age. For this, appropriate nutrition was the solution. Another was the
control of diarrhoea-related diseases by means of oral rehydration therapies, known
as ORT. The third sought to emphasise the nutritional and psychological importance of
 History of International Health   31

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

AIDS and New Epidemic Challenges

Whilst PHC and SPHC were being debated, a new and unexpected disease, HIV/AIDS,
altered the priorities of international agencies (see Whiteside in this volume). It was first
recorded in Los Angeles in 1981 in young homosexual men with a number of op­por­tun­
is­tic illnesses that usually affected old people or those with damaged immunological
systems, such as Pneumocystis carinii fungus and Kaposi’s sarcoma (Fee and Fox 1988).
Not long afterward, cases were recorded amongst haemophiliacs—who were dependent
on blood transfusions—and injection drug users. In the early years, stigmatising names
emerged, such as the 4-H disease because it seemed to affect Haitians, homosexuals,
haemophiliacs, and heroin users. The acronym GRID (gay-related immune deficiency)
reinforced the stigma. Once it had been determined that the disease was not limited to
the homosexual community, discriminatory terms were replaced by the acronym AIDS
(acquired immunodeficiency syndrome). Initially it was perceived as a disease of rich
countries, but by the mid-1980s it was clear that it was spread all over the world.
WHO was initially slow to respond to AIDS. The first director of the Global Program
for AIDS, created only in 1987, was the American doctor Jonathan Mann, under whom it
became WHO’s largest programme for addressing a single disease. For perhaps the first
time, medical investigations and public health interventions were put into practice
alongside human rights promotion, allowing a disease to be addressed concomitantly
from scientific, clinical, and political perspectives. Mann chided stigma and discrimin-
ation and promoted confidential testing and educational programmes as well as the use
of condoms as broad strategies for prevention (Fee and Parry 2008). The AIDS pro-
gramme promoted a greater cultural awareness and tolerance of sexual minorities and
was closer to the second socio-medical perspective described in this chapter, because it
placed emphasis on the social and cultural context of ill people and their partners and
families. Mann´s firm stand on international health helped to raise funds and make the
disease—and indirectly international health—a priority of ministers of finance and
presidents. However, Mann came into conflict with the director-general of WHO,
Nakajima, who did not agree with the programme’s scope, leading to the former resign-
ing from his position and moving to the United States. Sadly, he died in an airplane acci-
dent in 1998 on his way to a meeting of the recently established Joint United Nations
Programme on HIV/AIDS (UNAIDS), an agency directed by the Belgian doctor Peter
Piot, that brought together ten organisations of the UN system. UNAIDS became the
main driver for global action against AIDS and took over the leadership role from WHO
in its fight against HIV/AIDS.
In the wake of AIDS, during the final decade of the twentieth century outbreaks of old
and new bacterial, viral, and parasitical diseases occurred in unexpected places.
Examples include diphtheria in Russia in 1990, cholera in Peru in 1991, yellow fever in
Kenya in 1992, and bubonic plague in India in 1994, as well as dengue epidemics in Latin
America in 1996 and 1997. Scientists created two terms for the new epidemiological situ-
ation: emerging and re-emerging diseases. Both could appear in any part of the world
 History of International Health   33

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

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

Conclusion

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

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 chapter 3

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

Matthew Sparke

Globalisation is widely understood as a name for processes of global political-­

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

and ideational iterations that influence one another (Sparke 2013). Put another way,
this means coming to terms with neo-liberalism as a thread of policy and practise that
capitalist globalisation has spun and braided but by which it has also been bound and led.
As well as challenging the dualism dividing political economy from political-­cultural
analysis, this approach makes it possible to go beyond the conventional dualistic
depiction of public health security and international health intervention as simply
merging together to form global health as a result of globalisation. Instead, by high-
lighting how globalisation’s own integrative and ideational imperatives have been
bound together by neo-liberalisation, the chapter focuses on how the associated
norms and practises of pro-market governance have come to structure global health.
This helps answer calls for more critical reflexivity about the normative implications
of dominant global health governance definitions and metaphors (Bozorgmehr 2010;
Lee and Kamradt-Scott 2014; Stuckler and McKee 2008). But by also highlighting how
other non-neo-liberal traditions of global health have thereby been repressed, it sug-
gests that the politics of neo-liberalisation and its discontents keep returning to haunt
global health like contentious ‘ghosts in the machine’ (Bruen and Brugha 2014).
Their contestability and normativity notwithstanding, definitions of global health
that depict it as a merger of just two traditions remain a useful entry point into global
health politics. On the one side of this dualism lie depictions of a regime of global health
security with origins in traditions of national public health surveillance, disease preven-
tion, and precautionary regulation. On the other side of the dualism are accounts of a
regime of global biomedical humanitarianism with origins in traditions of international
intervention, tropical medicine, and disease-specific treatment programmes. The first
section of this chapter reviews how global health tends to be defined by narratives
describing the merger of these two regimes. After introducing the two-level definition
of globalisation, it further underlines how such depictions of a globalised convergence
of the two regimes need to be supplemented to accommodate the intersecting influ-
ences of neo-liberalisation and its discontents.
The second section of the chapter outlines the politics of neo-liberal conditionality and
austerity in which postcolonial visions of global health universality were subordinated to
selectivity. It begins with the damaging impacts of Washington Consensus neo-liberalism
on health systems and health outcomes globally. This neo-liberal consensus characteris-
tically came with arguments that ‘wealthier is healthier’. However, in response to the debt
crises of the 1980s, the World Bank, International Monetary Fund (IMF), and associated
economic elites enforced neo-liberalisation with structural adjustment programmes
(SAPs) that systematically undermined health and health systems. In rich and poor
countries alike, globalisation has further shrunk the policy space available to govern-
ments pursuing health equity, either by unleashing competitive market pressures that
undermine wages, social protections, and the tax base needed to fund social pro-
grammes, or by providing ideational alibis for further neo-liberalisation. Compounded
by more recent rounds of austerity, as well as rising in-country inequalities, fraying
social safety nets, and health-worker brain-drain dynamics, the results have included the
 Globalisation and the Politics of Global Health   39

widespread embodiment of neo-liberalism in increased disease vulnerability, suffering,

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

Globalisation and the Neo-liberal

Merger of Global Health’s ‘Regimes’

To begin with, let us consider how a doubled definition of globalisation that addresses
both its integrative and its ideational elements offers a way of coming to terms with how
its invocation can normalise neo-liberal policymaking. Most obviously, this is useful as
a way of explaining how such ideational framing pre-empts policies that might mitigate
40   Matthew Sparke

the health-damaging downsides of global economic integration and competition

(Rushton and Williams 2012). ‘Taming the inequality machine’, to use Ted Schrecker’s
critical formulation, is so much harder when health policies that might be introduced as
counter-measures are pre-emptively contested as being costly drags on growth and
competitiveness in the context of globalisation (Schrecker 2016). And even when it is
not invoked as an alibi for inaction on the social determinants of ill-health, the idea-
tional influence of globalisation discourse can work affirmatively alongside the material
market pressures of global competition to construct how the ‘global’ assumed in global
health frames policy (Legge 2016). Global scarcity is often assumed in this way as neces-
sitating global health priority-setting and cost-effectiveness studies in order to create
narrowed targets for global health investment (e.g., Jamison et al. 2013). By highlighting
the way such arguments involve distinctly neo-liberal assumptions about how to manage
increasing global interdependency and governmental convergence, a two-level defin-
ition of globalisation can contribute to the wider work of revealing the resulting
exclusions (Chiriboga et al. 2015).
To develop the doubled definition requires adding an extra critical step beyond the
‘three-step’ approach normally taken in introductory academic texts on globalisation
(following the model of Held et al. 1999). Conventionally these ‘three-step’ accounts
seek to move through the contested terrain of globalisation’s political meanings by
eschewing all the myth-making about it being a new, inevitable, and flattening juggernaut
of political-economic change. Thus their first step is to argue that hyper-globalisation
myths exaggerate when they lead to depictions of a smooth, hypercompetitive, borderless
world of market-based integration. Second, they nevertheless also argue that sceptics
who maintain that nation-states remain the fundamental political units of international
relations and political-economic governance fail to acknowledge the real transform-
ations that globalisation involves. And so third, the three-step accounts suggest it is best
to follow their own ‘transformationalist’ approach to globalisation, acknowledging
growing global integration and global governance, but also offering evidence-based
assessments of how the transnational ties vary in their transformational impacts based
on varied national, local, and historical factors. This measured transformationalist
approach remains an important analytical guide, but it overlooks what is at stake politically
in the divide between the hyper-globalists and the sceptics: namely, neo-liberalisation
(Sparke 2013).
Typically it is the normativity and advisability of pro-market policymaking that
hyper-globalists hype and sceptics scorn. Hyper-globalists tend to argue for the inevit-
ability of market-led neo-liberalisation in order to justify more pro-market adjustments.
By contrast, sceptics maintain claims about national sovereignty and political autonomy
in order to protect public and personal spaces for imagining alternative ways of man-
aging the integrative imperatives of globalisation. Reading accounts of globalisation this
way means taking care to notice how empirical claims about the integrative effects of
globalisation often become bound up with normative political claims about ‘Globalisation’
and synonyms such as the ‘Global Market’ (Steger, 2005). It also invites an ongoing
openness to alternative global imaginaries and political responses—including the
 Globalisation and the Politics of Global Health   41

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

politicians. Security arguments change the terms of the political debate’ (Horton 2017).
These sorts of strategic ties to security discourse by advocates of humanitarian biomedi-
cine have a proven history in securing funding in the West and are now also evolving in
complex new ways with the rise of BRICs (Brazil, Russia, India, and China) as emerging
economies (Gómez 2018). But however strategic they may be, global health merger
appeals tend also to gloss over huge ongoing political-economic asymmetries in North-
South relations that postcolonial advocates of PHC had once hoped to overcome. The
same globalist gloss also in turn elides the many ways in which global health partner-
ships are aligned with the geopolitical management of enduring North-South inequal-
ities (Herrick, 2017). This is where globalisation as ideation plays a role in obscuring the
inequalities and tensions structuring globalisation as integration.
Focused more on the differences between the traditions, the anthropologist Andrew
Lakoff has instead argued that the juxtaposition of the ‘two regimes of global health’
highlights ‘some of the tensions inherent in many contemporary global health initia-
tives’ (Lakoff 2010, 59). The ‘global’ in global health appears far less unifying and inclu-
sive in this account. Instead Lakoff suggests that these differences can lead to political
contradictions rather than just new funding for universities and treatment programmes.
His main example is the controversy surrounding Indonesia’s demands in 2007–2008
for access to vaccines in return for sharing flu virus samples with the WHO. From the
global health security perspective, the Indonesian health minister’s refusal to share sam-
ples without a promise of vaccine access was easily politicised as an affront to global
public health surveillance. But, Lakoff underlines, from the side of global humanitarian
biomedicine, Indonesia’s demands for equitable access to vaccines was tied closely to
health citizenship rights. He ends his essay after reviewing several other aspects of the
emerging global health security regime by suggesting that its evolving relationship with
global health humanitarianism might well be far more asymmetrical and parasitical
than the symmetrical and equitable synthesis suggested by Koplan and colleagues.
Given this politics, Lakoff concludes with a much more dystopian depiction of global
health expertise exchanges in which ‘humanitarian biomedicine could be seen as offer-
ing a philanthropic palliative to nation-states lacking public health infrastructure in
exchange for the rights of international health organisation to monitor their popula-
tions for outbreaks that might threaten wealthy nations’ (Lakoff 2010, 75).
Lakoff ’s politically provocative reframing of a fundamentally unequal global health
trade-off between, on the one hand, public health security protections for the wealthy,
and on the other, palliative care for the poor, aligns with other studies pointing to how
populations in the global South can thereby be turned into canaries in the cloudy mine
shafts of global health securitisation (e.g., Lowe 2010; Sparke and Anguelov 2012). Such
critiques of data mining through global health surveillance are further buttressed by lit-
eratures addressing other globalising processes of ‘bioprospecting’, ‘biocoloniality’, and
intellectual property extraction from the hinterlands of global health (e.g., Crane 2013;
Rajan 2006; Schwartz-Marín and Restrepo 2013). But as Simon Reid-Henry has high-
lighted, Lakoff ’s reduction of global health’s heterogeneity to just two political regimes
itself remains a simplification (Reid-Henry 2016). For the same reason, his depiction of
 Globalisation and the Politics of Global Health   43

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

Alma-Ata and Postcolonial World

Health Universalisation

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

in tropical medicine and sanitation strategies (Anderson 2006; Packard 2016). Despite
the resulting diversity of experiences, though, universalising health rights became a
common postcolonial goal globally.
After World War II, postcolonial concerns combined with post-war initiatives in
human rights internationalism to shape the global politics in which the constitution for
the World Health Organization (WHO) was drafted. As a result, its preamble famously
asserted that health was a fundamental human right, that it incorporated ‘complete
physical, mental, and social well-being and not merely the absence of disease or infirm-
ity’, and that it was the responsibility of governments to protect this comprehensive kind
of health citizenship ‘through the provision of adequate health and social meas­ures’
(Packard 2016, 89). As Randall Packard details in his history of global health, these
ideals were themselves inspired in part by a Depression-era tradition of social medicine
that had informed the Bandoeng Conference of 1937 in Java. As such, they also reflected
a basic interest in inclusive health equity and justice coming from the colonised parts of
the world. In 1946, amidst all the post-war and postcolonial hopes for rebuilding and
improving social welfare globally, the WHO constitution therefore came to affirm health
citizenship in its broadest socialised sense. However, amidst the growing conservativ-
ism of the 1950s, the Cold War, and US commitments to free market development, the
underfunded WHO returned to the technical, top-down, disease-specific approach to
international health advocated by its dominant donors: chiefly the US government and
the Rockefeller Foundation (see Cueto in this volume).
With the Declaration of Alma-Ata in 1978, the pendulum of policy swung back
radically (but briefly) in the direction of postcolonial health equity and universality.
Three thousand delegates from 134 countries attended, and the consensus reached
after seven days of deliberation reaffirmed WHO’s founding definition of health, health
rights, and associated government health responsibilities (Cueto 2004). This radical
rethink resulted from numerous intersecting influences, including the leadership of
WHO director Halfdan Mahler. But arguments from postcolonial countries tied to
the non-aligned movement and the G77 were key, including both their demands for
a new international economic order (NIEO) and their critiques of the failings of
Western-dominated development (Thomas and Weber 2004). Instead of the disease-
specific biomedical campaigns associated with such development, there was great interest
in the new model of PHC already being planned in countries such as Costa Rica,
Mozambique, Tanzania, China, and Cuba. Using community health workers, examples
of successful PHC also suggested that improvements in health outcomes could best be
sustained by commitments to social and economic welfare.
These were the ideals that were then encoded in the ten-point declaration that came
out of Alma-Ata, albeit without any detailed guidelines about implementation in par-
ticular country contexts, and also without any global funding. Packard suggests that
these drawbacks help explain why the health universality idealised at Alma-Ata was so
swiftly subordinated to top-down, disease-specific selectivity afterwards. He also sug-
gests that the lessons drawn from the success of smallpox eradication (and the failure of
WHO’s malaria eradication efforts) played a role too. However, he and many others
 Globalisation and the Politics of Global Health   45

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

The Washington Consensus and the

Conditionalisation of Global Health

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

should pursue in order to recover and develop amidst increasing global market inte-
gration. Trade liberalisation, privatisation, business deregulation, financial deregula-
tion, reduced taxation, and diverse forms of public sector austerity were promoted as
how countries should adjust to global market forces and restore stability to the global
financial system. These policies were then packaged by the IMF and World Bank and
imposed on the countries caught up in the debt crises in the form of SAPs.
Whilst the ideals of market-led development were what provided the ideational struc-
ture of SAPs, the reasons they could be enforced were tied to the material interdepend-
encies of the markets. In short, when the indebted countries defaulted on their debts to
private banks, they had no lenders to turn to except the World Bank and IMF. These two
DC-based international financial institutions stepped in principally to protect the inter-
ests of the banks and wealthy lending countries. However, they also used their power as
lenders of last resort to insist on the Washington Consensus reforms enumerated in
SAPs. Also known as ‘conditionalities’, these neo-liberal reforms were what then turned
the ideational entwining of neo-liberalisation and globalisation in the Washington
Consensus into a powerful conditioning influence on global health (Farmer 2015).
SAPs affected health outcomes through a wide range of causal mechanisms that were
both direct and indirect. Directly, SAP conditionalities had immediate negative impacts
due to budget cutbacks on health spending, education, and other forms of social protec-
tion. As well as imposing user fees for health services, they also imposed pay ceilings for
public sector employees such as health workers. These direct influences alone were
enough to make the government responsibilities for health declared at Alma-Ata impos-
sible to honour. But the indirect influences went much further in undermining the
promise of ‘Health for All’ by unleashing global market competition and enabling mar-
ket rule. Capsizing the commitment made to health as a fundamental human right,
advocates of structural adjustment tended to take a market fundamentalist view of
health as a commodity. Instead of Alma-Ata’s demands for an NIEO free from ‘unaccept-
able’ inequalities between rich and poor, and instead of seeking to advance PHC globally
with international cooperation, the idea was that economic growth would eventually
lead to good health. This was itself an idealistic and highly normative vision of a new
economic order, but it was a neo-liberal order founded on an idealisation of market rule.
By unleashing global market competition in the name of securing stabilisation amidst
globalisation, it bound the indebted countries under World Bank and IMF rule into a
straitjacket of forced neo-liberalisation.
Coinciding with the global AIDS epidemic, the impacts of structural adjustment on
health and health systems were devastating. The commodification and privatisation of
health services reduced the availability of both treatment and prevention options for
poor patients. The adoption of user fees failed to cover the costs of broader public health
measures such as education, sanitation, and even the collection of basic life and death
statistics. Health worker brain-drain dynamics that were set in motion in the context of
public sector pay cuts, and the increasing precariousness of employment in defunded
public health systems further deprived poor patients of reliable health services, includ-
ing the kind of primary health services close to home and work envisioned at Alma-Ata.
 Globalisation and the Politics of Global Health   47

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

Intellectual Property Rights (TRIPS) rules (Kapczynski 2009), and increasing ­restrictions
on generics with new ‘TRIPS plus’ rules on data exclusivity (UN 2016). Trade-based
competition from countries with lower taxes and lower protections for workers and the
environment intensified a ‘global race to the bottom’ in political, legal, and environmen-
tal standards, thereby creating a convergence between industrial and eco-social threats
to health whilst limiting the ability of governments to protect (Labonté et al. 2009,
Labonté and Stuckler 2016; Peckham et al. 2017). And in the heavily indebted poor coun-
tries (HIPC) of the global South, poverty reduction strategy papers (PRSPs) have picked
up where the much-critiqued SAPs left off, albeit allowing debt-disciplined govern-
ments to draft their own neo-liberal reform strategies in the name of ‘country owner-
ship’ (Pfeiffer and Chapman, 2010).
Reviewing these developments in 2008, the WHO Commission on the Social
Determinants of Health concluded: ‘Inequalities are killing people on a grand scale’
(WHO 2008, 6). The commissioners did not describe the associated mechanisms
explicitly as neo-liberalism, but they did highlight how the ‘structural drivers’ of ‘bad
policies, economics, and politics’ had gone global with globalisation. ‘These “structural
drivers”’, they concluded, ‘operate within countries under the authority of govern-
ments, but also, increasingly over the last century and a half, between countries under
the effects of g­ lobal­i­sa­tion. This toxic combination of bad policies, economics, and
politics is, in large measure, responsible for the fact that a majority of people in the
world do not enjoy the good health that is biologically possible’ (WHO 2008, 26).
Appearing in early 2008, the report was both perfectly timed and terribly timed. An
epic crisis of market-led globalisation rocked the world just as it was being published.
Vindicating the commissioners’ arguments about toxic economics and politics, but
also replacing their concern with all those left behind by global health improvements,
the crisis created a new frenzy of global concern with the ‘too big to fail’ economic
actors at the centre of the global meltdown. Yet again an ideational legacy of Alma-
Ata—in this case, the 2008 report’s systematic emphasis on the social determinants of
ill-health globally—was eclipsed by a material breakdown in the markets of economic
globalisation.
The following year, in an extraordinary speech before the World Health Assembly, WHO
director-general Margaret Chan did her best to bring back a critical social-determinants
approach to interpreting the multiple crises of neo-liberal globalisation. She too did
not refer to neo-liberalisation explicitly, but her epidemiological overview presented
a compelling critique of globalisation. ‘The rising tide of globalisation has not lifted
all boats’, she complained. ‘Instead, wealth has come in waves that lift the big boats
but swamp or sink many smaller ones’ (Chan 2009). Chan’s criticism of market-led
­globalisation perfectly summarised a widespread sense of disillusionment with the old
Washington Consensus. Good economic growth was not leading to good health. The
processes producing growth were instead creating uncontrollable crises in the basic life
support systems of the planet. But in the aftermath of similar announcements of disil-
lusionment by other world leaders, we have not seen a return of Alma-Ata commit-
ments to government-supported universal health rights. Instead, as we review in the
 Globalisation and the Politics of Global Health   49

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

Global Health Selectivity and

the New Washington Consensus

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

in bold in his 2014 foundation letter, is that ‘[h]ealth aid is a phenomenal investment’
(Gates 2014, 15). And in the same bolded format, the Lancet Commission’s Global Health
2035 report more recently reached the same consensus conclusion: ‘There is an enor-
mous payoff from investing in health’ (Jamison et al. 2013, 1898).
Even though its twenty-first-century advocates do not use the term, the New Washington
Consensus works as a name for this investment-oriented approach to global health gov-
ernance for at least four institutional reasons—in addition to the fact that the Gates
Foundation is based in Seattle, Washington, rather than in Washington, DC. First of all,
the New Washington Consensus has clearly grown out of policy adjustments made by
the World Bank itself amidst the calls for structural adjustment with a human face.
Second, the new ‘common sense’ has involved policymaking shifts at WHO and the
development of new global health agencies—most notably the Global Fund to Fights
AIDS, Tuberculosis and Malaria (the Global Fund) and the Global Alliance for Vaccines
and Immunisations (GAVI)—that have amplified the arguments about health invest-
ments leading to global economic growth. Third, the New Washington Consensus
really is new in its twenty-first-century commitment to creating global networks of
public-private partnerships, many of them organised in ways that sideline national
governments whilst making micro-market innovations designed to tackle the health
problems created by macro-market failure. And fourth, the New Washington Consensus,
just like the old consensus before it, is clearly not a global consensus, but rather a dominant
policymaking regime with diverse critics who contest the beneficent vision of targeted
health investments leading to healthy, productive lives for all. As we shall now review, all
of these developments are connected in turn to evolving debates and discontents about
the neo-liberalisation of globalisation.
Both at the World Bank and amongst other economists in DC, the original Washington
Consensus was supposed to encourage investments in PHC and education. This was
in fact the second reform on Williamson’s original list of ten consensus norms
(Williamson 1990). The problem was that all the upheaval and austerity forced on
indebted countries by SAPs made such investments by national governments impos-
sible. Nevertheless, back in 1993 the seeds of the World Bank’s new solution were sown
in the form of the influential Investing in Health report (World Bank 1993). The report
contained much of the normal consensus cant about achieving health through the
pursuit of pro-market, macroeconomic growth policies, but it also included a new
SPHC-inspired attention to making targeted, cost-effective investments in ‘minimum
packages’ of interventions such as immunisations. To rank and justify the priority of
such packages in terms of return on investment, the report in turn presented metrics
of the global burden of disease (GBD) as measured in terms of disability adjusted life
years (DALYs), the latter being calculated as the sum of years lost to premature death
and to life lived with disease and disability due to a comprehensive list of causes. The
goal of creating this single ­globally comparable metric was to enable cost-effective-
ness comparisons of the number of DALYs averted by different targeted interventions
per dollar spent, thereby enabling the comparison of returns on investment by type of
intervention, cause of illness, and country across the whole world. Critics highlight
 Globalisation and the Politics of Global Health   51

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

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

Conclusion: Global Health Politics

amidst Antiglobalisation Reaction

If, as Youde has argued, ‘global health governance itself has woven its way into the nor-
mative fabric of international relations’ (2017, 583), the central argument of this chapter
is that the thread of neo-liberalism has been woven into this fabric through a series of
norm-setting ties that bind. From the eclipse of Alma-Ata by structural adjustment and
Washington Consensus reforms in the 1980s and 1990s, to the rollout of New
Washington Consensus norms of targeted cost-effective interventions in the new mil-
lennium, we have seen how this thread has twisted and turned. Creating structural vio-
lence, vulnerability, and ill-health in one turn, it has also gone on to be twisted into the
conceptualisation and advocacy of idealised solutions in the next turn. Through all
these twists and turns, neo-liberalism has clearly bound and led global health gov­ern­
ance globally, nationally, and personally. And because it is also now so clearly bound up
 Globalisation and the Politics of Global Health   53

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

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 chapter 4

The Politics of
Gl oba l H e a lth
I n equa lities
Approaches to Studying the Role of Power

Yusra Ribhi Shawar and

Jennifer Prah Ruger

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

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

The Study of Health Inequalities

Research on health inequalities and inequities is substantial and growing. Health

inequality refers to the ‘differences, variations, and disparities in the health achieve-
ments of individuals and groups’, whilst health inequity pertains to ‘those inequalities in
health that are deemed to be unfair, stemming from some form of injustice’ and/or are
unavoidable or unnecessary (Dahlgren and Whitehead 1991; Kawachi, Subramanian,
and Almeida-Filho 2002, 647). The former is a dimensional concept, referring to meas­
ur­a­ble quantities, whilst the latter suggests a moral commitment to social justice. Whilst
recognising the overlap of the two terms and the explicit link that health inequity has to
politics and power, given that understanding a health indicator difference that is rooted
in a form of injustice necessitates an investigation of power, we use health inequality in
this chapter, given its inclusivity of a broader body of scholarship.
Measurement of health inequalities often involves comparing an indicator of health
or a health-related factor in one or more disadvantaged groups—for example, women,
the poor, racial or religious minorities, or other populations that consistently experi-
ence societal disadvantage—with the same indicator in a more advantaged group or
groups (Braveman 2006) or analysing shortfall inequality (Ruger 2006; Ruger and
Kim 2006). Over several decades, this body of research has made important contribu-
tions by pinpointing many underlying drivers of health inequalities (e.g., CSDH 2008;
Marmot 2010), identifying linkages between health inequalities and individual behav-
iours and risk factors (e.g., Kawachi, Daniels, and Robinson 2005), and evaluating the
 Politics of Global Health Inequalities   61

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

The Conceptualisation of Power

in Global Health Scholarship

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

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

The Study of Power in Relation

to Health Inequalities

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

Anthropology
Scholars have drawn widely on concepts and methodologies from anthropology and
critical medical anthropology to study the role of power in health inequalities. In par-
ticular, anthropology has advanced the concepts of ‘structural violence’ and ‘structural
vulnerability’ as central concerns to understanding how power is embedded in, and
produced by, societal structures and discourses.
 Politics of Global Health Inequalities   63

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

is performed and analysed within the situational knowledge provided by long-term

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

Political Science
Researchers studying health inequalities have also drawn on concepts and methodolo-
gies from political science, and in particular political economy, to understand the role of
power. Through a political economy lens, researchers studying health inequalities con-
sider how social classes, occupations, and parties, for example, act through political and
economic systems at the state level to influence the allocation of resources, which in
turn impacts health outcomes (Coburn 2010). In particular, this approach investigates
the effects of income equality via the spread of neo-liberalism; the decline of the welfare
state; differences amongst states regarding type of welfare regime; and the broad dynam-
ics amongst class structure, economies, and human well-being (Coburn 2004).
Adopting a political economy lens, scholars have also examined how the power
exerted through political ideology (i.e., neo-liberalism), trade liberalisation, and/or the
business practises of transnational corporations shape the public policies that create and
sustain health inequalities (Navarro 2002, 2007; Navarro and Muntaner 2004;
Chernomas and Hudson 2007; Raphael 2014). For example, economists Chernomas
 Politics of Global Health Inequalities   65

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

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

of others (Weber and Parra-Medina 2003). Accordingly, through an examination of

power relations encompassed in institutions, Sainsbury (2006) examines the dispropor-
tionately negative impact of welfare reforms in the 1990s on immigrants’ and non-
citizens’ social rights. Greer Murphy (2017) investigates the impacts of recent austerity
policies on women’s health. Scott et al. (2017) draw upon the concept of social spaces in
their investigation of how power inequalities are produced through village health, sani-
tation, and nutrition committees (VHSNCs) in rural India, which were established to
encourage community participation in health promotion activities and strengthen
community relations with related government services. ‘Social spaces’ (Lefebvre 1991)
refer to ‘moments in space and time, constructed through relationships between diverse
groups, which create contexts for new social representations and identities to emerge’
(Duveen and Moscovici 2000). The authors trace the ways in which the VHSNCs influ-
ence power relations (i.e., around gender) within communities and how the rationale
for participation framed by outside stakeholders influences community collective
agency (Scott et al. 2017).
Power in the sociological health inequalities literature has also been studied through
an examination of stigma. Historically, studies of stigma were mostly drawn from social
psychology, highlighting the impact of attitudes associated with stigma on discrimin-
atory practises and ultimately health outcomes. More recently there has been growing
acknowledgement of the central role of power, with stigma defined as the ‘relations of
power and exclusion that reinforce vulnerability within a complex social and political
process’ (Parker 2012). From a sociological perspective, stigma is thus defined as ‘the
co-occurrence of labelling, stereotyping, separation, status loss, and discrimination in a
context in which power is exercised’ (Link and Phelan 2001).
Sociologists offer useful studies of how stigma manifests in healthcare encounters,
community discourses, and even national policies, producing health disparities in specific
populations, such as those with HIV and AIDS (Davtyan et al. 2017); transgender popu-
lations (Poteat, German, and Kerrigan 2013); and those living in particular geographies,
known as ‘place-based stigma’ (Bush, Moffatt, and Dunn 2011; Cattell 2001; Popay et
al. 2003; Pearce 2012; Keene and Padilla 2014; Thomas 2016). For example, in their exam-
ination of how stigmatisation functions in healthcare encounters between transgender
patients and medical providers, Poteat, German, and Kerrigan (2013, 22) find that the
uncertainty and ambivalence of providers when interacting with transgender patients
in the medical encounter ‘upsets the normal balance of power in provider-patient rela-
tionships’. Accordingly, interpersonal stigma functions to reinforce the power and
authority of the medical provider during these interactions.
Researchers studying health inequalities have also examined the ways in which the
wealthy and powerful shape policies in ways that contribute to health inequalities—a
strand of research that remains under-explored (Garthwaite et al. 2016). This body of
literature builds on particular threads of Marxist or neo-Marxist theory (Muntaner
et al. 2015; Scambler and Scambler 2015; Raphael and Bryant 2015) and employs
­historical materialism, a methodology that focuses on human societies and their
development throughout history; it argues that history is the result of material condi-
tions rather than ideas. It often is used in analyses and critiques of the development
 Politics of Global Health Inequalities   67

of capitalism. In particular, sociologist Graham Scambler (2002, 2007, 2009, 2012)

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

Critical Theory

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

Critical Race Theory

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

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

Intersectionality
Scholars examining health inequalities have also begun to draw upon intersectionality—
a theoretical perspective and methodological lens for conceptualising, analysing, and
responding to health inequalities by ‘making visible the fluid and interconnected
structures of power that create them’ (Larson et al. 2016). Derived primarily from crit-
ical feminist studies and encompassing ideas from the black feminist, indigenous
feminist, third-world feminist, queer, and postcolonial literatures, intersectionality
was a concept coined by the American sociologist Kimberlé Crenshaw. Her analysis
conceptualises the multiple disadvantages experienced by black women, which can-
not be accounted for via methods that consider race and gender as distinct categories
(Crenshaw 1989).
In this way, intersectionality ‘promotes an understanding of human beings as shaped
by the interaction of different social locations’ (Larson et al. 2016). This includes gender,
 Politics of Global Health Inequalities   69

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

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

Studying Power in Health Inequality:

The State of Scholarship

The previously described literature as a whole, with its varied conceptualisations of

power and location across a number of social sciences, embodies several strengths.
First, two major categories of power are investigated in understanding health inequality:
 Politics of Global Health Inequalities   71

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

seek to draw on or expand upon existing social science scholarship. This includes Nye’s
(2009) ‘hard power’, which refers to the use of payment and coercion, often via eco-
nomic or military might, to make others comply; Goehler’s (2000) ‘transitive power’,
which concerns one actor overruling the will of another; and Haugaard’s (1997) ‘con-
flictual power’, which (aligned with Weber, Dahl, and Lukes’s concepts of power) occurs
when power is exercised by one actor over another.
Similarly, little health inequalities scholarship is situated within existing social science
scholarship that sheds light on power exhibited via an actor’s indirect control over
another actor’s health experience or access to healthcare via an institution or agent (i.e.,
organisation or agreement). Whilst some health inequalities scholarship considers
‘institutional power’, few investigators draw on the related concept of ‘dispositional
power’, whereby actors are positioned in organisations in relation to each other, and that
these positions determine what actors may accomplish (Clegg 1989). Rules and resources
typically facilitate this process of positioning. For example, this is observed in the
Agreement on Trade-Related Aspects of Intellectual Property Rights-Plus (TRIPS+)—
an international legal agreement amongst all the member nations of the World Trade
Organization—which has restricted LMIC access to knowledge and medicine whilst
benefiting certain multinationals in high-income countries. In the same way, a consid-
erable body of health inequalities literature studies power via stigma, structural violence,
or structural vulnerability; however, little of this scholarship considers the related con-
cepts of symbolic and soft power. The former, advanced by Bourdieu (1991), refers to the
unconscious form of social or cultural control that is observable in one’s routine social
habits. The latter, described by Nye (2009), concerns the ability to co-opt or attract using
cultural or economic influence.
An additional limitation of this literature is that particular forms of power are far
less studied. Whilst this literature considers various agentic and structural forms of
power, there is little study of a less visible but potentially more widespread form of
power in global health: ‘productive’ (Barnett and Duvall 2005) or ‘epistemic’ power
(Shiffman 2014). This type of power is expressed as ‘the socially diffuse production of
subjectivity in systems of meaning and signification’ (Barnett and Duvall 2005, 43).
Shiffman (2014, 297) interprets this form of power as the way in which meaning is cre-
ated, ‘particularly through the use of categories that lead us to think about the world
in some ways but not others’. This type of power is similar to normative (influence
derived from moral authority) and ideological (influence based on the necessity of
meaning to social life) power concepts. Gramsci’s (1999) ‘hegemonic power’ is also
comparable, referring to the often-unrecognised dominance of particular perspec-
tives that produce agreement amongst groups by making particular social and cultural
behaviours the norm, undetectable and therefore unchallenged. This is analogous to
‘non-decision-making power’, which refers to an actor’s ability to determine the topics
on an agenda and make particular topics appropriate or inappropriate for consider-
ation (Lukes 1974). More empirical studies of this form of power are especially needed,
given that it is one of the least examined and obvious, yet is so critical in shaping
health inequality. For example, future research could consider how power is expressed
 Politics of Global Health Inequalities   73

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

Ways Forward for Studying and

Addressing Health Inequality

This chapter concludes by highlighting power frameworks that as of yet have been
underutilised in the health inequalities research and study approaches that may be
undertaken and expanded for not only study of, but action on, health inequality. Whilst
scholars have begun engaging with and broadening the disciplinary base of health
inequalities research to the social sciences with deep traditions of thought in the domains
of power, as outlined in this chapter, additional analytical frameworks are reviewed.
In terms of analytical frameworks, two are highlighted that may be helpful to the
study of health inequalities. The power cube framework (Gaventa 2005), derived and
mostly used in the field of international development, is useful for simultaneously ana-
lysing the levels (local, national, and global places of decision-making and authority),
spaces (closed, invited, and claimed arenas for participation and action), and forms of
power (visible, hidden, and invisible manifestations) and their interrelationship. The
framework may be helpful in examining the interwoven ways in which power drives
health inequalities; it also highlights how transformative change around health inequal-
ity can only occur in those exceptional instances when movements or actors are able to
successfully work across each of the dimensions (levels, spaces, and forms of power)
concurrently.
The Barnett and Duvall (2005) typology is useful in examining how power is chan-
nelled. Specifically, the typology recognises that power works through various social
interactions (wielded by an actor over another or through structures and processes
that differentially enable and constrain the capacity of an actor to shape its fate) and
has varied effects (specific and direct interactions or diffuse and indirect dynamics).
Accordingly, the typology describes four concepts of power according to these two
analytical dimensions (Barnett and Duvall 2005). Compulsory power refers to ‘the dir-
ect control of one actor over the conditions of existence and/or the actions of another’
(i.e., high-income countries exerting control over LMICs via development aid).
Institutional power concerns an ‘actors’ indirect control over the conditions of action
of socially distant other’ (i.e., the advancement of structural adjustment policies in
LMICs by the World Bank and the International Monetary Fund). Structural power
refers to ‘the co-constitutive, internal relations of structural positions’ (i.e., refugees’
structural disempowerment is shaped by the stigma they may experience, local and
national policies, and their legal status, resulting in healthcare access and health out-
come inequalities). Productive power works through ‘diffuse constitutive relations to
produce the situated social capacities of actors’ (i.e., who is involved in the research
process, the ways data are analysed and interpreted, and the extent to which the find-
ings are accessible have important health equality implications). The typology has
been applied to study power dynamics in global health—for example, explaining how
states exerted power in the establishment and institutionalisation of the Millennium
 Politics of Global Health Inequalities   75

Development Goals (MDGs) (Marten 2019)—and would also be beneficial to an

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

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

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 chapter 5

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

Alan Ingram

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

A Brief Genealogy of
Critical Thinking

The global health field as it exists today can be thought of as having emerged in the wake
of the Enlightenment, the intellectual movement that developed in Europe in the
seventeenth and eighteenth centuries. In broad terms, this movement sought the
progressive elimination of suffering, want, and oppression and the enhancement of
freedom via the application of reason and rationality to human affairs. Global health can
therefore be understood as a critical project to the extent that it embodies these ideals.
However, whilst it might appear to be self-evidently progressive, the Enlightenment
project has itself come to be viewed much more critically in light of its apparent implica-
tion in the horrors of colonialism, two world wars, and the Cold War. As many thinkers
have observed, the pursuit of progress through reason is tangled up with the exercise of
power, and, as discussed in this chapter, the ostensibly progressive intentions character-
istic of the global health field have themselves been subject to critical appraisal.
The work of Immanuel Kant is fundamental to the Enlightenment understanding of
critical thinking. As Kant wrote in a footnote in the preface to the first edition of the
Critique of Pure Reason ([1781] 1933, 9, note a): ‘Our age is, in especial degree, the age of
criticism, and to criticism everything must submit. Religion through its sanctity, and
law-giving through its majesty, may seek to exempt themselves from it. But then they
awaken just suspicion, and cannot claim the sincere respect which reason accords only
to that which has been able to sustain the test of free and open examination’.
For Kant, criticism meant subjecting matters to systematic questioning and reason-
ing in an open and public way; any authority that claims exemption from such scrutiny
is thereby not worthy of ‘sincere respect’. Critical thinking can thus be thought of as
being fundamental to both modern scientific activity and modern ideas of rights, dem-
ocracy, freedom, and the public sphere. In the essay What Is Enlightenment, Kant ([1784]
2009, 1) urged, ‘Sapere aude!’: dare to know! Enlightenment is the emergence from
dependence on authority, achieved through the exercise of systematic, rigorous, and
reflective thought and inquiry.
Though such ideas might seem to be self-evidently progressive, the scope and
implications of the Enlightenment have always been contested. Whilst the import of
Enlightenment ideals is ostensibly universal, many European thinkers held that
­freedom and equality could only be extended to sufficiently capable and responsible
subjects, who were invariably understood to be property-owning men of Western
European heritage. Liberal thinkers often thought that ‘civilised’ and ‘uncivilised’
populations would have to be governed in fundamentally different ways: whilst the
civilised could exercise reason, freedom, and equality in a responsible way, paternalistic
or harsh measures would always be required for others, whose best interests would be
decided for them (Duffield 2007).
 Critical Approaches to Global Health   87

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

were sometimes also associated with regional identities like pan-Africanism, pan-
Arabism, and pan-Americanism. Ideas of national and regional identity combined
with distinct ideas of gender and household structure: to be a healthy citizen of a
nation invariably meant contributing to its growth, development, and flourishing in
particular ways, for example by giving birth to a certain number of children and raising
them in line with ideas of the public good. Ideas about health were therefore funda-
mental to ideologies of development, and the extent of a country’s success in, for
example, vaccination programmes, extending public infrastructure, or improving
nutrition and education came to be seen as indicators of political success.
Today’s global health field has emerged in large part out of the crisis of these models of
health, development, and progress, and amidst the growing influence of ‘neo-liberal’ ideas
and policies, according to which state and society ought to be re-engineered in terms of
private economic interests (Harvey 2005). Emerging during the 1970s, these ideas have
increasingly affected health and health policy around the world. In 1982 interest rate
increases by banks based in the global North triggered debt crises across many countries
that had borrowed to finance development in the 1960s and 1970s. In return for bailing
them out, the International Monetary Fund (IMF) and World Bank, backed by govern-
ments in the global North, sought to shrink the public sector and expand the private.
Public health services were defunded; across much of sub-Saharan Africa, Latin
America, and South Asia, and with increasing speed across post-communist countries
after 1989, many standard indicators of health and development went into reverse. ‘Old’
diseases like cholera, malaria, and tuberculosis made a comeback, and ‘new’ diseases,
most notably HIV, emerged, in a world that was becoming ever more connected. The
models credited with producing health and wealth for some seemed to entail the oppos-
ite for others.
In this context, the idea that health had to be understood in ‘global’ rather than ‘inter-
national’ terms began to gain ground amongst policy communities as well as academics
(Brown, Cueto, and Fee 2006). Influential here was the work of journalist Laurie Garrett
(1995, 2000), who diagnosed the global health problems of the 1990s primarily in terms
of a lack of political awareness and responsibility. Focusing on the problem of emerging
infectious diseases, she argued that governments and political leaders had largely failed
to give health issues adequate priority and had failed in their duty to ensure the provi-
sion of adequate health infrastructures and services. In light of globalisation, policy-
makers had to give new priority to health and ought to consider it a security issue
alongside defence and strategic policy. Though telling, Garrett’s account remained
rather circumscribed in terms of its analysis of power and politics. A contrast can be
drawn with the work of anthropologist and physician Paul Farmer (1999, 2003), which
illustrates more fully what critical thinking in global health has come to mean. For
Farmer, the policy shifts of the 1980s and 1990s emerged from, and served to exacerbate,
long-term, deep-seated patterns of racial oppression, political disempowerment, and
economic disenfranchisement. Here Farmer’s work is exemplary in challenging narrow
framings of global health problems and advancing fundamental criticism of the social,
economic, cultural, and political relationships in the midst of which they emerge.
 Critical Approaches to Global Health   89

Critical Thinking in Global Health

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

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

Varieties of Critique

It is further possible to disentangle different varieties of critique in global health. At one

level we can identify critique as an inherent facet of intellectual inquiry, in that it means
subjecting any account of the world to systematic questioning and scrutiny. Many stud-
ies use analytical tools to scrutinise how power, politics, and policy affect both health
outcomes worldwide and the institutional field of global health governance. One influ-
ential reference point has been the ‘health policy triangle’ advanced by Gill Walt and
Lucy Gilson (1994), which enables analysts to unpack instances of health policymaking
in terms of the contexts, actors, and processes at work, then to identify different kinds of
power that may be in play in a given situation (Gilson et al. 2008). Such heuristic (or
descriptive-interpretive) approaches are useful in that they can quickly enable people to
begin thinking about power and influence in global health, Whilst indicating where fur-
ther investigation might be useful.
A further example of systematic, questioning analysis is the work of David Fidler
(e.g., 2008, 2010) on the politics of epidemics, global health diplomacy, and global health
security. Fidler’s work shows how, despite attempts to build global health surveillance
 Critical Approaches to Global Health   91

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

The Critique of Political Economy

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

critical analyses insisted that these downsides were indeed inherent to ‘neo-liberalisation’
(Navarro 2007). A central task of critical analysis here has been to expose what is held to
be the ideological (i.e., false and biased) nature of dominant ideas.
The thought of the Italian communist Antonio Gramsci has been influential in this
regard. Gramsci (1971) analysed the political situation of early twentieth-century Italy
and came to the conclusion that part of the reason that communist revolutions had not
been successful was that certain sectors of society that might have been expected to rally
to the communist cause had embraced ideas that ultimately served the capitalist class.
Dominant sectors of society had insulated themselves politically by propagating capital
friendly ideas throughout society, in culture as well as in politics and economics, endow-
ing an unequal society with undeserved legitimacy. The continuation of capitalism was
thus secured not just by coercion but also by the production of consent. This could be
achieved by establishing certain patterns of thought as unquestionable ‘common sense’.
The struggle for a better society would accordingly include the attempt to shift common
sense to a position friendly towards what was held to be genuine social progress. The
battle of ideas was as important as practical organisation, and if revolution was not pos-
sible, it was still important to fight to establish an understanding of the situation that was
correct from a critical point of view. This would enhance the prospects for revolutionary
change should the political situation shift.
This background enables us to understand why many critical theorists considered
neo-liberal ideas of globalisation to have become ‘hegemonic’—that is, to have achieved
the status of ‘common sense’, from which all (or most) would benefit and only the
deluded or deficient would dissent. A large part of critical global health analysis during
the 1990s and since (e.g., Thomas and Weber 2004; Navarro 2007) has accordingly been
concerned to expose and challenge these ideas by showing how neo-liberal policies have
been implicated in health crises and how this has stemmed from the dominant role
played by the IMF, World Bank, and World Trade Organization (WTO) in global health
policy. Much critical global health analysis has therefore been engaged in what Marx
(1859) called the ‘critique of political economy’, of dominant ideas of politics and eco-
nomics. Some analysts have further linked this critique with others, for example, linking
feminist and political-economic critiques of international responses to HIV/AIDS
(O’Manique 2005) or interpreting new epidemic alert and response systems as in some
sense neocolonial, to the extent that they involve the projection of ideas and technolo-
gies developed in the global North into other areas of the world (Weir and Mykhalovskiy
2007). Such critiques promote ideas of emancipation from domination and typically call
for more democratic structures and processes within global politics.
If Critical Theory approaches to global health gained ground amidst the struggles
of the 1990s, the theoretical landscape has to some extent shifted since then in tandem
with changes in the global health field. Around the year 2000, a combination of social
movement mobilisations, critical academic analysis, and scientific and political alarm
contributed to major shifts in global health governance. Donor states began to pledge
increasing amounts of overseas development aid (ODA) for health (albeit targeted
towards a highly selective range of problems). After having been largely sidelined in
 Critical Approaches to Global Health   93

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

Debating Product (RED)

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

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

The Critique of Representation

Whilst such debates have been taking place, research has also explored how global
health politics is shaped by what has been called the politics of representation. The
argument is that how people represent the world to themselves and each other has
important consequences for what happens in the world. A central point here is that
prejudicial stereotypes about other people and places help to make and sustain unequal
power relationships; our ideas and images of the world do not simply reflect a pre-
existing, material reality, but help to bring that reality about. This line of thinking also
implies a potential remedy: perhaps we can change the world by representing it differ-
ently. A clear example of this is work towards the destigmatisation of people living with
HIV, to which the effort to shift language and imagery has been central.
This line of thinking has been particularly influential in international relations (IR)
work on global health, which has examined what IR theorists call ‘securitisation’ (Buzan
et al 1998; Balzacq 2011). The underlying thrust of securitisation theory is that saying
something is ‘a security issue’ is more than a description; it also sounds the alarm and
calls for action. Because governments consider security their overriding priority, so the
reasoning goes, getting a problem recognised as a ‘security issue’ can lead to its increased
prioritisation. The clearest example of this seeming to work is in relation to HIV/AIDS,
which the US government and the United Nations accepted as a security issue around
the year 2000, thereby adding force to international responses (Elbe 2006, 2010;
McInnes and Rushton 2010). Securitisation theory counts as a critical theory in three
ways. First, it helps us to think about power and politics: for a securitising speech act to
be successful, it must be made by a figure with authority; that is, the security ‘speech act’
 Critical Approaches to Global Health   95

requires some form of political power in order to be successful. Second, it encourages

reflection on the potential downsides of political ‘success’: securitisation theorists high-
light that there are many dangers to invoking ‘security’, especially where this leads to
normal political processes being suspended or bypassed (theorists have also debated
how far the theory applies in situations where exceptional powers are the norm). Third,
securitisation theory reminds us that just changing our representations is not enough
on its own; we need to think about how language connects to other forms of power.

The Critique of Biopower

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

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

The Stakes of Critique

This concluding section considers the relevance of ongoing debates on the wider stakes
of critique for the field of global health, thereby offering reference points for further
reflection. One criticism of critical theory is that it is always seeking to unveil, reveal, or
expose something that we supposedly cannot otherwise perceive. A useful starting
point here is the philosopher Paul Ricoeur’s (1970, 33) description of Marx, Friedrich
Nietzsche, and Sigmund Freud as ‘masters of suspicion’. As Ricoeur observes, Whilst they
advanced very different ideas, each of these thinkers proposed to expose what he saw as
the false nature of consciousness and to reveal how our sense of the world is actually
determined by something else, whether this be (respectively) the mode of production,
the will to power, or the unconscious. According to these theorists, our understanding
of the world and ourselves is always false and needs to be exposed as such in order for
real understanding and emancipation to become possible. A simplified parallel of this
narrative in global health might be the (in critical terms, ideologically misled) consumer
who buys a (RED) iPod, incorrectly believing themselves to be helping to end the
AIDS epidemic. If consumers could only break the ‘commodity fetish’ and gain critical
knowledge and awareness (e.g., that concerted governmental action is a primary solu-
tion and that corporations should be taxed and regulated rather than celebrated and
empowered), they might then be in a position to transform themselves and the world.
The literary theorist Rita Felski uses Ricoeur’s idea of suspicion as a starting point
for enumerating the main elements of critique as an academic activity. As she notes,
‘critique is negative’: ‘To engage in critique is to grapple with the oversights, omissions,
 Critical Approaches to Global Health   97

contradictions, insufficiencies or evasions in the object one is analysing’ (Felski 2012).

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

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

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 pa rt I I

GL OBA L H E A LT H
A N D T H E W I DE R
P OL IC Y AGE N DA
 chapter 6

Gl oba l H e a lth
Dipl om acy

Akram Khazatzadeh-Mahani,
Arne Ruckert, and Ronald LabontÉ

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

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

Global Health Diplomacy:

Definition and Origins

Global health has developed into an area of study distinct from international health. The
latter term captures international cooperation on high disease burdens and inadequate
health systems in developing countries, emphasizing issues such as access to healthcare,
disease prevention programs, and medical treatments. Global health, in contrast, deals
with health issues that transcend national boundaries in cause and consequence and
places a normative priority on achieving health equity worldwide, sharing with inter-
national health an emphasis on improving the health of vulnerable populations (Koplan
et al. 2009). The term ‘diplomacy’ has a long pedigree, its modern meaning having been
popularized by Edmund Burke in 1796. Defined simply, it refers to the negotiations
among officials of various countries to reach their disparate foreign policy objectives
without having to resort to war (Kickbusch et al. 2012). In practice, diplomacy can exer-
cise ‘hard power’ (economic sanctions and military operations), ‘soft power’ (co-option
and cooperation), or more likely both hard and soft power combined in ‘smart power,’
using various modalities and actors to achieve foreign policy goals (Novotny and
Kevany 2013; Nye 2004). Global health diplomacy (GHD), a merger of the two concepts
global health and diplomacy, is a more recent term and has been defined as the multilevel
and multi-actor negotiations that shape the global policy environment for health
(Drager and Fidler 2007; Kickbusch, Silberschmidt, and Buss 2007). This includes the
 Global Health Diplomacy   105

various ‘processes through which States, intergovernmental organizations, and non-

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

The Link between Health

and Foreign Policy

The link between health and foreign policy has grown stronger over the past two dec-
ades, to the point that global health issues have become normalized in foreign policy,
106   Akram Khazatzadeh-Mahani et al.

High politics/hard power

National security

Economic interests

Development

Human dignity

Low politics/soft power

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

partly because of the massive increase in health funding linked to the Millennium
Development Goals (MDGs) (Feldbaum, Lee, and Michaud 2010; Feldbaum and
Michaud 2010). Grasping such change, Fidler has developed a conceptual framework,
see Figure 6.1, to show how the relationship of health with the basic functions of foreign
policy has changed over time, outlining a hierarchy of foreign policy functions, from
human dignity and development to economic and national security, and linking each
function to health (Fidler 2005a; Thieren 2007). Categorizing foreign policy objectives
as ‘high politics’ and ‘low politics’, a long-standing distinction in the field of inter-
national relations (Morgenthau 1962), the framework shows that health historically has
been categorized as ‘low politics’, dealing with scientific, non-political, and humanitar-
ian activities; here international health activities are considered ‘mere humanitarianism’.
It was only after World War II, through the Constitution of WHO in 1946 and the
International Covenant on Economic, Social, and Cultural Rights in 1966, which linked
health to human rights, that the relationship between health and foreign policy deep-
ened as human rights became an issue in Cold War diplomacy (Fidler 2005a). The end of
the Cold War led to the securitization of health as the perception of security threats
changed, which meant that ill health was now seen as a potential destabilizing force in the
international system, especially as HIV/AIDS spread rapidly in developing countries.
However, there has been limited empirical examination of the interactions between
health and foreign policy (Feldbaum, Lee, and Michaud 2010; Kickbusch 2011), and
there has been difficulty in distinguishing between means and goals: Is health a conduit
for other (non-health) foreign policy objectives, or is foreign policy a means to directly
improve health outcomes (Kickbusch 2011)? Lee and Smith (2011) elaborate on these
differences; in the first instance, health is a means to achieve other foreign policy goals,
such as increasing health aid to reduce the risk of conflict in strategically important
countries or regions. In the second instance, other foreign policy goals are used to
enhance health, such as adapting trade policy to positively discriminate in favor of
healthy foods (Labonté 2014; Lee and Smith 2011). In a similar vein, Kickbusch (2011)
outlines four possible interactions between foreign policy and health: foreign policy
 Global Health Diplomacy   107

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

Foreign Policy Endangering Health

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

Health Serving as a Foreign Policy Tool

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

relationships reflect the way high-income countries (HICs) try to impose their own
agendas, values, worldviews, and predefined objectives on recipient nations (Buss and
Ferreira 2010). A concrete example of this is the gross mismatch between global health
needs, as measured in global disease burdens, and donor priorities expressed in
development assistance for health flows. Since the 1990s the global burden of disease
in developing countries has shifted substantially, away from infectious diseases to
non-communicable diseases (NCDs), yet most development assistance remains focused
on infectious diseases, arguably as a strategy to contain such diseases at the source
before they spread to HICs.
Governments also increasingly use health programs to strengthen their relations with
other countries, to help build alliances, and to increase their political reputation. While
such forms of ‘medical diplomacy’ have a long history, they have recently accelerated
with China’s incursions into Africa and Cuba’s international medical assistance pro-
grams (Thompson 2005). China’s foreign policy interests and political cooperation with
Africa include mostly energy and food assistance, as well as infrastructure projects and
medical collaboration, while Cuba has sent more than 100,000 medical personnel to
over one hundred countries since the 1960s. In this process, Cuban medical teams have
played crucial roles in many of the world’s health disasters, including combatting the
2014 Ebola outbreak in West Africa (Kendall 2015). More recently, under the ‘Oil for
Doctors Program’, Cuba has ensured access to Venezuelan oil at subsidized cost in
return for providing Venezuela with 30,000 doctors and training for 40,000 Venezuelan
medical personnel annually.
In a similar vein, the United States has also used medical diplomacy in its war
efforts, through the US President’s Emergency Plan for AIDS Relief (PEPFAR),
which was started in 2003 under George W. Bush. Introduced at the time of the inter-
nationally criticized Iraq war, its aim was not solely humanitarian, but served to
improve recipient countries’ perceptions of the United States. It proved to be a suc-
cessful program in health terms, leading to large reductions in infection rates and
mortality (Bendavid 2016), as well as adding a humanitarian legacy to the Bush presi-
dency (Kickbusch 2011). Similarly, Brazil, despite its recent economic turmoil, is con-
sidered a rising global power and has used its international health programs—including
making available low-cost antiretroviral drugs and being a strong voice globally on
improving access to medicines—as foreign policy instruments to reinforce its devel-
oping international status (Wogart et al. 2008). For example, it has successfully lever-
aged its program to fight HIV/AIDS into an expanded South-South cooperation
effort to serve its wider foreign policy goals of reforming the UN Security Council
and the international monetary system (Gómez 2009). Finally, the then prime min-
ister of Canada used the 2011 G8 summit in his country to launch a widely recog-
nized global health initiative, the G8 Muskoka Initiative on Maternal, Newborn and
Child Health, as a way to garner international recognition and to position Canada as
a major player in the multilateral health arena (Hoffman 2010; Kirton and Guebert
2009; Proulx et al. 2016).
 Global Health Diplomacy   109

Using Foreign Policy to Promote Health Goals

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

Health Serving as an Integral Part of Foreign Policy

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

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

Global Health Diplomacy as

a Soft Power Tool

In achieving foreign policy goals, diplomatic efforts surrounding health are often
understood in terms of the exercise of ‘soft power’, a term first used by the US academic
Joseph S. Nye in the early 1990s to describe a country’s ability to persuade and attract
others to do what it wants without resorting to coercion. Nye defines power as ‘the
ability to influence the behavior of others to get the outcomes one wants’ (Nye 2004, 2)
and distinguishes between ‘hard’ and ‘soft’ power. For Nye, hard power rests on threats
(‘sticks’) or inducements (‘carrots’), while ‘soft power’ or ‘the second face of power’ seeks
to obtain the outcomes one wants indirectly and without tangible trade-offs or resorting
to economic threats and sanctions. In other words, soft power co-opts others rather than
coercing them into action and ‘rests on [one’s] ability to shape [their] preferences’ (Nye
2004, 5). In contrast to hard power’s deployment of military power and economic
resources, soft power is exercised through the diffusion of values, institutions, culture,
and attraction. In world politics, a country may reach the outcomes it wants because
other countries admire its values, aspire to its level of prosperity, and emulate its example.
Global health diplomacy is largely based on the exercise of soft power (Lee and Smith
2011), and some have suggested that the growing focus on health in global political
 Global Health Diplomacy   111

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

Instruments of Global
Health Diplomacy

Much of the extant literature on GHD highlights the central role played by WHO
through its executive board, the World Health Assembly, and side meetings and special
working groups, which provide the main platforms for GHD negotiations (Solomon
2013). The WHO Constitution offers authority and normative capacity to the World
Health Assembly (the decision-making body of WHO, consisting of its member states)
to adopt and approve normative and legally binding instruments (see box 6.1). As a nor-
mative entity, WHO sets global standards and norms (e.g., international agreements,
regulations, conventions, and recommendations), acts as a powerful voice in debates
about health in development, and leads and coordinates global health research (Yach
2016); however, it has seldom exercised its normative power through legally binding
instruments (Gostin and Sridhar 2014). Nominally the world’s paramount health
or­gan­iz­ a­tion, WHO presently faces multiple legitimacy challenges, some related to its
112   Akram Khazatzadeh-Mahani et al.

Box 6.1 The WHO’s Diplomatic Instruments

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

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

How and Why Do Health Issues Reach

the Foreign Policy Agenda?

While the processes by which GHD occurs have been well described in the literature,
there is no consensus on what is driving the proliferation of health diplomacy in various
global fora or on how and why health issues are increasingly integrated into foreign pol-
icy negotiations (Ruckert et al. 2016). One of the few empirical studies in GHD that
addresses these questions is that of Gagnon and Labonté (2013), which explored the UK
global health strategy (2008–2013) using three theoretical frames: Walt and Gilson’s
policy analysis triangle, Fidler’s conceptualization of health and foreign policy drawing
on realist theory of international relations, and Kingdon’s multiple streams framework
(Kingdon 1984). Invoking realist theory, Gagnon and Labonté argue that national and
international security and economic interests were the main driving forces behind the
United Kingdom’s decision to focus on global health. But additional drivers to embark
on global heath include the desire to improve the United Kingdom’s international
 Global Health Diplomacy   113

reputation, as well as an organized policy community and a dedicated policy entrepreneur

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

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

Evaluating GHD

Global health diplomacy covers a wide range of processes, from developing binding and
non-binding GHD instruments to finalizing agreements between bilateral or multilateral
aid donors and recipient countries. There remains a lack of reliable evidence about the
effectiveness of such efforts (Smith and Irwin 2016), with calls for more empirical
evidence on the diplomatic and health effects of soft power initiatives (Kickbusch 2011).
Sporadic evidence reveals the success of GHD-led programs like PEPFAR in terms of
their impact on mortality (Bendavid 2016); for example, Bendavid and Bhattacharya
(2009) reported a 10.5 percent drop in HIV-related mortality in twelve countries receiv-
ing aid from PEPFAR. As another example, Kevany and colleagues (2015) report on the
success of the Global Fund in advancing altruistic and diplomatic goals simultaneously.
They argue that global health programs have contributed considerably to non-health
goals such as the pursuit of national integration/internal unity, development, and
regional international relations in South Pacific countries, while having a significant
impact on the control of communicable diseases and health system strengthening
(Kevany et al. 2015). Recently conducted health impact assessment (HIA) studies of
regional trade agreements (e.g., the TPP) also constitute part of this evidence (e.g.,
Hirono et al. 2016; Ruckert et al. 2017). Yet critical questions that remain largely
unanswered, as initially outlined by Lee and Smith (2011) and reaffirmed by Smith and
Irwin (2016), include the following:

• How can the quality of GHD initiatives be measured in terms of their effective-
ness, accountability, transparency, and representativeness?
• How should GHD success or failure be assessed?
• What sort of qualitative and quantitative methods are required for GHD
evaluation?
• How are GHD outcomes implemented at the national level?
• How effective are institutions/agencies in formally conducting GHD (e.g., WHO)
functions?
• Which venues are most effective for conducting GHD?
 Global Health Diplomacy   115

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

Conclusion: The Way Forward in GHD

This chapter outlines some of the key aspects and discussions of how health has increas-
ingly become a political concern in global fora, leading to diplomatic efforts to solve glo-
bal health problems. It demonstrates the political nature of GHD processes, which can
be simultaneously driven by security and economic interests, as well as by broader
norms and values. While GHD negotiation processes have been well-described and
116   Akram Khazatzadeh-Mahani et al.

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

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

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 chapter 7

Secu r it y a n d H e a lth

Simon Rushton

over twenty-one million passengers pass through Washington, D.C.’s, Dulles airport
every year (MWAA 2016). Most of those journeys are uneventful. That could not be said
of the journey of Thomas Eric Duncan, who arrived at Dulles on September 20, 2014, on
flight UA951 from Brussels, Belgium. After clearing immigration, Duncan boarded a
flight to Dallas/Fort Worth. In Dallas he fell ill—and was eventually diagnosed with
Ebola virus disease (EVD). On October 2 the New York Times reported that Duncan had
lied at Monrovia airport before boarding his Brussels-bound flight, denying having had
any contact with the disease despite having helped take an Ebola patient (who died of
the illness on September 16) to hospital. Binyah Kessselly, chairman of the Liberian
Airport Authority, was quoted as having said that Duncan would be prosecuted upon
his return to Liberia (Onishi and Santora 2014). Duncan never did return; he died in the
Texas Health Presbyterian Hospital on October 8. Two nurses who had treated him also
contracted the disease; both recovered.
Only a few days before Duncan landed at Dulles, on September 16, President Barack
Obama had used a speech at the Centers for Disease Control and Prevention (CDC)
in Atlanta as an opportunity to address public fears about the threat posed to the
population of the United States by the Ebola outbreak then under way in West Africa.
Obama said:

First and foremost, I want the American people to know that our experts, here at the
CDC and across our government, agree that the chances of an Ebola outbreak here
in the United States are extremely low. We’ve been taking the necessary precautions,
including working with countries in West Africa to increase screening at airports so
that someone with the virus doesn’t get on a plane for the United States. In the
unlikely event that someone with Ebola does reach our shores, we’ve taken new
measures so that we’re prepared here at home. We’re working to help flight crews
identify people who are sick, and more labs across our country now have the capacity
to quickly test for the virus. We’re working with hospitals to make sure that they are
124   Simon Rushton

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

Evidence that subsequently emerged, including in the congressional hearings

­following Duncan’s death, pointed to failures related to each of those promises. Duncan
had been able to board a flight; he was not successfully diagnosed on his first visit to
hospital; and infection control procedures within the hospital had failed, leading to the
two nurses contracting the disease. Representative Tim Murphy, chairing the congres-
sional hearing, said that ‘[t]he trust and credibility of the administration and government
are waning as the American public loses confidence each day, with demonstrated
failures of the current strategy’ (cited in Morgan 2014).
The Ebola virus Thomas Duncan was carrying inside his body was widely interpreted
as not only a medical or public health problem, but also a national security threat to the
United States and its population—and a potential global security threat. The Duncan
case provided a classic illustration of a number of debates that have surrounded the
concept of ‘health security’ at both the national and global levels (Aldis 2008). First, to
what extent was it possible for the United States to prevent importation of the virus in a
highly globalised world? Second, could the threat Ebola posed to the United States best
be addressed at the US border, or should greater effort be put into containing the
­outbreak in West Africa? Third, were the domestic preparedness measures that Obama
had announced on September 16 adequate, or should more effort and resources have
been put into readiness for a potential US outbreak? Fourth, how should infected
individuals (and those thought to be at risk of infection) be dealt with? To what extent
should their civil liberties be restricted? Strikingly, all four of these questions could, with
only minor amendment, be asked about many other contemporary security challenges,
not least the threat of international terrorism. This goes to show how deeply entrenched
the securitisation of disease is in American political discourse and that of many other
countries of the global North.
‘Security’, however, remains a contested concept. As is evident in other chapters in
this volume (see, e.g., chapters by Enemark and Nunes), a wide range of different under-
standings of ‘security’ can be applied to health and disease, from relatively traditional
understandings of ‘national security’, in which states seek to protect their territories,
populations, and economies from outbreaks of deadly diseases, to more human-centred
or critical accounts that focus on the threats posed to individuals and communities.
Each of these approaches to security leads to different answers to the questions of
who or what is being secured, from what, and how that security should be achieved in
practise (Aldis 2008).
This chapter examines and critiques the ways in which diseases have come to be seen
as national and international security threats. It begins with a brief examination of the
long history of disease as a threat to societies, then turns to the deepening linkages
between disease and national security in the post–Cold War era. The chapter then
examines four health threats that have found their way firmly onto Western security
 Security and Health   125

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

Disease and Insecurity: A Brief History

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

Gregory Bankoff finds in contemporary discussions of Western vulnerability to disease

a continuation of a very similar discourse, which

denigrates large regions of the world as dangerous—disease-ridden, poverty-stricken

and disaster-prone; one that depicts the inhabitants of these regions as inferior—
untutored, incapable, victims; and that it reposes in Western medicine, investment
and preventive systems the expertise required to remedy these ills.
(Bankoff 2001, 29)

The earliest international efforts by governments to develop transnational cooperative

mechanisms to mitigate the risk posed by the cross-border spread of pathogens fit neatly
into these colonial logics, with their focus on protecting Europe from less ‘civilised’ (and
more disease-ridden) parts of the world. Such efforts are most commonly traced back to
the International Sanitary Conferences of the mid-nineteenth century, which brought
together European states concerned with harmonising quarantine regulations to
control cholera, plague, and yellow fever. The gradual institutionalisation of these
international arrangements (Hoffman 2010) led ultimately to the adoption of the
International Sanitary Regulations (ISRs—later renamed the International Health
Regulations (IHRs)) by the newly established World Health Organization (WHO) in
1951 (WHA 1952). In 2005 WHO member states adopted the most recent revised set of
IHRs (which remain in force at the time of writing), widely seen (not least by WHO) as
being the centrepiece of global arrangements to provide for ‘global health security’.
Whilst disease is often spoken of as a ‘new security challenge’, only emerging on
mainstream national security agendas in the post–Cold War era, the idea that disease
poses a security threat is not new. Szreter (2003) has argued that it is the separation of
health and security rather than their coming together that is relatively recent. Yet it is
clear that something changed in the 1990s and early 2000s. National security and public
health policy communities increasingly found themselves discussing the same issues,
and doing so in similar terms. The extent to which (particularly Western) security policy
communities have added health issues—especially infectious diseases—to the range of
threats that they routinely concern themselves with is striking. Health threats have
become a fixture on national security agendas in much of the developed world, chan-
ging the way in which security is practised and leading to what Stefan Elbe (2010) has
termed a ‘medicalisation of security’.
The ending of the Cold War, which had dominated national security policymaking
for decades, is generally credited with having opened up space on the agenda for issues
such as infectious disease (e.g., Buzan 1997). Yet it is also the case that the concerted
efforts of some in the public health community to frame certain health issues in security
terms played an important part in constructing disease as a national security threat. The
next section examines the ways in which certain health-related issues have been ‘securi-
tised’—that is to say, have come to be commonly defined as security threats. In particular
it focuses on the four health issues that have become most firmly embedded on Western
national security agendas, showing how, from the 1990s onwards, the health and security
 Security and Health   127

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

The Construction of Health

Security Threats

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

Emerging Infectious Diseases

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

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

HIV/AIDS
Although as far back as the 1980s US intelligence agencies had begun investigating the
possibility that high levels of HIV/AIDS could be a threat to the stability of states in sub-
Saharan Africa (CIA 1987), it was around the turn of the millennium that the links
between AIDS and security began to be seriously discussed at the international level
(McInnes and Rushton 2010). The inclusion of AIDS on the agenda of the UN Security
Council in January 2000—the first time that body had ever discussed a health issue—
has been widely understood as a seminal moment not only in the securitisation of HIV/
AIDS, but also in the securitisation of health more widely. As with EIDs, advocates from
 Security and Health   129

both the public health and the security policy communities argued for greater account
to be taken of the security implications of AIDS. From the health side, Peter Piot, a virolo-
gist who was then head of UNAIDS (the Joint United Nations Program on HIV/AIDS),
was an influential supporter of getting AIDS on the Security Council’s radar. He was
(and is) explicit that this was part of a broader strategy to increase high-level political
attention and commitment to tackling HIV/AIDS. Piot later wrote about the Security
Council’s discussion of the subject as a ‘tipping point’ in the global response to AIDS:

In the space of a year, it became an urgent, unavoidable subject for world leaders and
organisations. . . . We succeeded in elevating AIDS to levels at which no health issue
had ever been discussed before—to where the heavy lifting of international and
national politics takes place. (Piot 2012, 273)

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

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

By the late 1990s it had become common to talk about the ‘new’ terrorism, carried out
by groups who were more likely to be religious in inspiration rather than pursuing expli-
citly political aims like those of the 1960s, 1970s, and 1980s (e.g., Laqueur 1999). Such
groups, it was said, would be more willing to carry out mass-casualty attacks and to kill
themselves in the process. They would be less amenable to negotiation with govern-
ments. Developments such as the internet and mobile communications gave them new
ways to organize and prepare attacks. And the collapse of the former Soviet bloc gave
them new opportunities to create weapons of mass destruction (WMD)—or even to get
hold of ready-made WMD. That such groups could draw upon expertise or materials
from the collapsed Soviet biological weapons programmes, or that they might develop
their own ‘in-house’ capacity to create such weapons, seemed logical—almost inevitable,
even—to many security policymakers.
Public health officials were also alert to the threat. The CDC, for example, put signifi-
cant resources into preparing for a potential bioterror attack, creating preparedness
plans, stockpiling vaccines and antivirals, and running simulation exercises to test and
improve the public health response (https://emergency.cdc.gov/bioterrorism/prep.asp).
Public health’s centrality to any such response also offered an opportunity to make a case
for greater investment in key public health infrastructure that would, it was argued,
strengthen the response to both naturally occurring and malicious disease events. In the
United States in particular, spending on biodefence increased markedly in the wake of
the 2001 attacks, building on pre-existing claims for the value of such investments. As
Senator Bill Frist said one week before 9/11:

Arms control negotiators have used the term ‘dual use’ to refer to biologic production
facilities that have the potential to be used by some countries to produce vaccines
for children one week and then produce bacteria or viruses for biological weapons
the next. But we can use the term ‘dual use’ differently: The same infrastructure
investments used to prepare our public health communities, doctors and federal
agencies to detect, diagnose and respond to a smallpox epidemic resulting from a
biologic attack can also be used to detect and respond to outbreaks of natural occur-
ring diseases like West Nile. (Committee on Foreign Relations 2001, 103)

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

Antimicrobial Resistance
Antimicrobial resistance refers to bacteria, viruses, and fungi having developed re­sist­ance
to the drugs that have been developed to kill them. Resistance has been recognised as a
 Security and Health   131

problem since antimicrobials were first invented, with resistance to sulphonamides

being reported as early as the late 1930s (Davies and Davies 2010, 418). In more recent
years, however, AMR has come to be seen as a more pressing public health problem due
to a combination of increased use of drugs, especially antibiotics (in both humans and
animals), leading to the more rapid and extensive emergence of resistant strains, and a
shortage of new antimicrobial drugs coming onto the market. The rise of AMR has led
some to fear that we will soon find ourselves living in something akin to the pre-antibi-
otic era, with even minor surgical procedures being highly dangerous as a result of the
risk of infection by untreatable bacteria (e.g., Ventola 2015).
As with EIDs and HIV/AIDS, over time drug resistance has come to be spoken of not
only as a public health problem, but also as a national security threat. Once again, the
push for securitisation has come from a combination of agents from the worlds of health
policy and security policy. In the United Kingdom the government’s chief medical
officer, Dame Sally Davies, has been a prominent advocate for AMR to be recognised as
a national security threat. In 2011 Davies released a report that described antimicrobial
resistance as a ‘catastrophic threat’ and argued:

There is a need for politicians in the UK to prioritise antimicrobial resistance as a

major area of concern, including it on the national risk register (specifically, the
‘National Security Risk Assessment’) and pushing for action internationally as well
as in local healthcare services. (Chief Medical Officer 2011, 16)

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

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

The Benefits of Securitising Health

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

Security Threats Generate More Concerted Responses

One of the common claims for disease’s status as a national security issue, particularly
prominent in the EID, bioterrorism, and AIDS cases, but also present to some extent in
the AMR case, is that diseases (whether naturally occurring or deliberately spread) can
cause political, social, and economic disruption and therefore need to be recognised (and
responded to) as security threats. Andrew Price-Smith (2009, 20–22) notes that the
impacts of major outbreaks include economic impacts (e.g., through reduced productiv-
ity, disruption to foreign trade, and the destabilisation of markets); governance impacts
(e.g., undermining a government’s ability to operate in the normal way, and reducing the
effectiveness of the institutions charged with upholding law and order); and impacts on a
state’s international relations (such as an increase in cross-border migration or the impos-
ition of travel restrictions). It is clear that severe outbreaks of infectious disease could lead
to all of these impacts, and some of the common measures (such as ‘social distancing’,
which often involves the closure of schools and public transport) put in place in response
to an outbreak can also have detrimental effects on society and the economy.
In an attempt to mitigate such disruption, states frequently enact emergency
measures during outbreaks, and even in ‘normal times’ many states have engaged in
activities such as preparedness planning—in theory making populations safer than they
would otherwise be when and if a health emergency occurs. Such planning has been
particularly in evidence around a potential future influenza pandemic—one of the most
prominent EID concerns—as well as around bioterrorism (see also the chapter on bi­o­
se­cur­ity by Enemark, in this volume). The majority of developed Western states have
developed influenza pandemic preparedness plans (e.g., Council of Australian
Governments Working Group on Australian Influenza Pandemic Prevention and
Preparedness 2011; Homeland Security Council 2005; Public Health Agency of Canada
2006; Public Health England 2014). These types of activities have only occurred, the
argument goes, because political leaders have been persuaded that their national
security is at stake, causing them to address the threats with an urgency that (arguably)
would not exist for ‘mere’ public health threats.
 Security and Health   133

Collaborations between Security and Public Health

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

Securitisation Brings Attention and Resources

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

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

Sacrifices for Security

Despite the enthusiasm of some in the public health community for getting health issues
on the security agenda, the international relations literature has generally been critical
of the securitisation of health, pointing to some of the downsides inherent in ‘playing
the security card’ (e.g., Elbe 2011). It has been argued, for example, that the kinds of
emergency responses that securitisation promotes can undermine international
cooperation, can be injurious to civil liberties and human rights, and can lead to the glo-
bal health agenda becoming distorted towards prioritising the small number of diseases
seen (by the West) as security threats, rather than those that cause the greatest levels of
sickness and death worldwide.
All of these critiques hold some truth. In practise, however, policymakers are left with
the difficult task of striking an appropriate balance amongst competing policy objectives,
norms, and principles. The questions they often face are not whether security from dis-
ease should or should not override their other concerns, but (1) how much security we
need from disease threats, given that in a globalised world we can never be 100 percent
secure, and (2) what we are prepared to sacrifice to achieve that level of security. In the
final section I examine three such ‘trade-offs’ that have to be made by policymakers in
responding to (and preparing for) health security threats.
 Security and Health   135

Human Rights and Civil Liberties

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

Travel and Free Trade

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

unilateral border closures and trade and travel restrictions caused significant economic
losses and hindered the flow of responders and supplies to the Ebola-affected
 Security and Health   137

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

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

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

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

Conclusion

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

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 chapter 8

Gl oba l Hea lth a n d

H um a n Secu r it y

Robert L. Ostergard Jr.

and Jeffrey A. Griffin

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

that dominate the global health agenda. Global health threats to populations are examined
in the context of the importance of state capacity.

The UNDP’s Human

Security Framework

When compared to the main body of international relations and international security
research, the concept of human security is relatively recent, though the concept itself is
not new. As Rothschild (1995) argued, the idea of ‘common security’ or ‘human security’
characterised state security from the mid-seventeenth century to the time of the French
Revolution; the military sense of the idea of security dates from the Revolutionary and
Napoleonic Wars (Rothschild 1995, 60–61). In contemporary times, the UNDP brought
the issue of ‘common security’ to the forefront in 1994 when it introduced its new focus
on a people-centred approach to security: human security. Conceptually, human security
contained two major components: freedom from fear, which encompassed freedom
from violence and abuse, and freedom from want, which encompassed freedom from
chronic conditions and threats. With the signing of the Universal Declaration of Human
Rights in 1948 and the International Covenant on Economic, Social, and Cultural Rights
(ICESCR) in 1966, the United Nations clearly emphasised first-generation human rights
focused on freedom from fear over second-generation rights that emphasised freedom
from want. (UNDP 1994, 24). This was understandable given the emphasis on physical
integrity and political rights following the atrocities of World War II. During the
decolonisation period of the 1960s and 1970s, however, issues of economic and social
rights became more prevalent, particularly in the context of the postcolonial states’
development agendas.
In 1994 the UNDP turned its focus to the developmental problems that a large portion
of the world’s population had faced for nearly three decades since the ICESCR. The
UNDP highlighted four essential characteristics of the human security agenda that
incorporated both the freedom from fear and freedom from want concepts. First,
human security was a common concern for all. People around the world face common
threats that transcend state and regional divisions such as ‘north-south’ or ‘developed’
and ‘developing’ countries. Unemployment, crime, pollution, drugs, and human rights
violations all exemplify population threats that are not just problems of the developing
world; they are problems of people globally. Second, human security issues are inter-
dependent and transcend state boundaries. For more than 350 years, the Westphalian
system of sovereign states emphasised state independence, whereby security stressed
protection from external interference by other states. In the context of the human secur-
ity agenda, however, territory does not limit conditions that threaten freedom from fear
and freedom from want. Leaders cannot consider famine, floods, pollution, terrorism,
ethnic disputes, and epidemic diseases isolated events, confined to a constructed state
 Global Health and Human Security   145

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

Human security, in its broadest sense, embraces far more than the absence of violent
conflict. It encompasses human rights, good governance, access to education and
health care and ensuring that each individual has opportunities and choices to fulfil
his or her potential. Every step in this direction is also a step towards reducing
poverty, achieving economic growth and preventing conflict. Freedom from want,
146   Robert L. Ostergard Jr. and Jeffrey A. Griffin

freedom from fear, and the freedom of future generations to inherit a healthy
natural environment—these are the interrelated building blocks of human—and
therefore national—security. (UN Secretariat 2000)

Based on Annan’s conceptualisation, human security became ipso facto national security,
a problematic association that has continued to plague the human security paradigm.
The Secretary-General had directly connected human and national security whilst
unwittingly highlighting the conceptual problems that have followed the human
security agenda. Annan’s linkage did little to clarify the human security agenda; on the
contrary, it resulted in confusing its initial conceptual issues. Given the extent of his
claim, there was virtually nothing that could be ruled out as national security.
Researchers further muddied the human security waters by expanding the concep-
tual framework to include arguments that ranged from those that merited serious
discussion, such as global epidemics, to those that did not merit consideration, such
as whether rhinoceros poaching constitutes a security problem (Humphreys and
Smith 2014). Such overreach ignored the reality of differential state capacities whilst
also bypassing the issue that the state was, and still is, the central actor in the inter­
national system.
The attempts to clarify this conceptual fuzziness occurred in the form of a scaling
back and narrowing of what appeared to be an overly grand agenda for human secur-
ity advocates. MacFarlane (2004) emphasised the lack of a specific objective in the
human security agenda, noting that such a broad agenda makes it difficult to priori-
tise specific policies. Buzan echoed this strain of thought whilst highlighting the
problem of collapsing two distinct agendas: ‘The idea [of human security] also risks
mixing up the quite different agendas of international security, on the one hand, and
social security and civil liberties, on the other. There is certainly a case for studying
the interplay between the international and domestic security agendas, but my con-
cern is that human security aims more at collapsing them than at opening up their
relationship’ (Buzan 2004, 370). But even Buzan’s analysis is dated in an oversimpli-
fied dichotomy between domestic and international politics rooted in the long evolu-
tion of security literature that denied domestic politics mattered for international
relations (see, e.g., Waltz 1979).
The relationship between human security and national/international security
presents a rich field of inquiry for understanding how the two security dimensions
are related. The human security agenda, similar to the human rights agenda, is an
aspirational framework. Governments bring distinct problems to bear upon their
populations either through direct assault on their own populations (or other populations)
or through the lack of capacity that governments possess in confronting problems
their populations face daily. The former is an issue of human rights and international
law; the latter is an issue of both political and economic development that has,
­unavoidably, the state as the primary provider of security to its population. Thus, the
paradox of the state and its population is at the centre of the security nexus between
human and national security.
 Global Health and Human Security   147

Human Security and State Capacity

Whilst some policymakers and scholars sought to advance the human security agenda,
others highlighted the contradictions present in the juxtaposition between the state and
its population. How can populations be secured whilst bypassing the state and its
security? Fukuda-Parr and Messineo highlight the issue: ‘The Commission on Human
Security [discussing broad versus narrow conceptualisations of human security] . . .
emphasises the involvement of multiple actors beyond the state—NGOs, regional
organisations, civil society in managing human security, and empowerment of people
as an important condition of human security and emphasise that state security and
human security are “mutually reinforcing and dependent on each other”’ (2012, 6). To
put the issue more succinctly, the capacity of the state affects the security of its popu-
lation, Whilst the security of the population affects the capacity of the state. Just as
important, however, it is also the case that certain problems transcend the basic tenets
of the state (territory and population), and the ability of the state to contain these
problems is limited by its capacity.
At its foundation, the state is comprised of population, territory, and a government.
The research on state capacity has tended to coalesce around governments having multiple
capacities that must be fostered and perpetuated to secure all three state components.
Thus, we can think of state capacity or ‘good governance’ as having four dimensions
(Grindle 1996; also cited in Kjaer and Hansen 2002):

• Institutional capacity refers to states having agreed-upon rules that orchestrate

political and economic activity, Whilst also having an agreed-upon method to
enforce them. Whilst this may be a subset of other areas of capacity, it is critical
that the institutional mechanism be in place before the actual policy implementa-
tion process can occur.
• Technical capacity is the ability to formulate and manage macroeconomic policies.
Those policies must meet the expectations of the population, promote the welfare
of the citizenry (including securing economic development), and acquire the
resources to operate the government.
• Administrative capacity describes effective administration of basic government
infrastructure for development and social welfare—that is, bureaucracy.
• Political capacity entails effective and legitimate outlets for social demands, repre-
sentation, and conflict resolution, conducted by competent leaders and adminis-
trators. The state’s legitimacy and its institutions are the focus, but so is the
government’s ability to protect the citizenry through institutions such as the mili-
tary (Grindle and Thomas 1991).

Holistically, state capacity captures the capability of governments to carry out specific
governmental functions that embody some of the core elements of human and traditional
148   Robert L. Ostergard Jr. and Jeffrey A. Griffin

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

State A State A
Population Government

State B State B
Population Government

Figure 8.1 State and population security threats.

 Global Health and Human Security   149

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

Global Health and the Commission

on Human Security

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

complete physical, mental and social well-being’, then health is both directly and
indirectly related to the nature of human security. Ogata and Sen (2003) strongly affirm
this linkage and argued that ‘health security is at the vital core of human security—and
illness, disability and avoidable death are “critical pervasive threats” to human security’
and note that the two concepts are ‘inextricably linked’ (2003, 96–97):

Good health is instrumental to human dignity and human security. It enables

people to exercise choice, pursue social opportunities and plan for their future.
A healthy child can learn, grow and develop. An adult cured of tuberculosis can
resume work to support the livelihood of her family. Saving a child’s life can secure
the future generations of a family. The absence of good health can result in enormous
grief (the loss of a newborn or young child) and can precipitate an economic catas-
trophe for the family (the sudden death of a working adult).
(Ogata and Sen 2003, 96)

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

Global Health and Violence

Global health scholars have had a difficult time situating a human security focus within
traditional boundaries of international relations, as the primary focus within the discip-
line has been on violence between states. Even then, international relations’ research
has questioned the relative importance of the state, with the notion of the system of
states being omnipotent to explain how states behave. Thus, the focus for international
relations for more than two millennia has been on trying to explain macro-level
­violence, with the normative goal being not to repeat history’s most devastating global
conflicts. Whilst war is still a relatively rare phenomenon, the concept of violence in
international politics has expanded significantly in the human security agenda, with the
conceptual expansion reflected in the focus on violence within and between popula-
tions and not just state-to-state violence. This approach also meant that the discussion
about violence had to move beyond just macro-level theories of war (such as trade and
democracy and their relationship to conflict) to meso- and micro-level theories that
affect populations.
In the context of human security, violence has a central role in making people
insecure at state (macro), societal (meso), and personal or interpersonal (micro)
 Global Health and Human Security   151

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

g­ overnment checkpoints) and rumours about how the epidemic started (through
intentionally poisoned water wells) led to riots and interpersonal violence in
St. Petersburg (Bosin 2009). When an outbreak of plague occurred in 1994 in Surat,
India, even though only fifty-six people died, there was so much short-term hysteria
that the country experienced massive population flight within just four days—about
one-quarter of the city’s population (Huang 2015).
The breakdown of public health can also occur during cataclysmic events. Such a
situation evolved after the 2010 earthquake in Haiti, which killed approximately 300,000
people and led to over 700,000 cholera cases, as the country’s public health system
collapsed under the weight of the earthquake and the spiked demand for medical services.
Riots against government and UN relief workers erupted (Tran 2010). The government’s
weak capacity to deal with such a cataclysmic event resulted in a massive outpouring of
assistance to help the Haitian people and to stabilise the government. A more recent
example is the 2014–2015 West African Ebola outbreak. As the epidemic ravaged Guinea,
Liberia, and Sierra Leone, the ability of these governments to contend with their
respective outbreaks quickly declined. Violence broke out as frightened people attacked
healthcare workers and prevented patients from receiving treatment.
Thus, the relationship between conflict and health is complex and multidirectional.
Conflict also has a direct relationship to poverty, another human security problem.
Poverty exacerbates health issues within and between states. It affects the state’s ability to
deliver health services and highlights the internal disparity between the wealthy, who
can access healthcare, and the poor, who most often do not have healthcare. This problem
is not limited to low-income countries but also afflicts high-income countries. Conflict
impacts the health problems of the most vulnerable victims: women, children, and the
elderly. Women in particular face health problems rooted in their general impoverish-
ment and the cultural biases towards them in many countries. Poverty paves the way
for low literacy rates, which impede health knowledge and development of healthcare
systems and contribute to high fertility rates, lower life expectancy, higher infant
mortality rates, and the greater gender inequalities that promote a general insecurity
amongst women in many countries (Boesten and Poku 2009). Importantly, a growing
body of empirical evidence finds that gender inequality significantly hinders a country’s
ability to develop economically. Gender inequality thus inhibits states from providing
needed health infrastructure whilst impoverishing women and forcing them into
de­pend­ent relationships that may be harmful to their health. This problem puts females
at an increased risk for a broader spectrum of health problems, including prenatal
problems and sexually transmitted infections (including HIV/AIDS) (Drimie 2003;
World Bank 2001; Gaffeo 2003). On a micro level, interpersonal violence has been
categorised as a global health crisis most affecting women. Women’s health issues can
reflect the norms and social values that are prevalent within states where they are virtu-
ally second-class citizens in their own country. Whilst these values do not necessarily
transcend states as part of an escalation or evolutionary process, many states have in
common the cultural denigration of women and their status within societies.
Women’s unequal rights in marriage, divorce, and inheritance, and their exclusion
 Global Health and Human Security   153

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

often left without assistance. Moreover, conflict can disrupt specialised medical care
and medicinal regimens, whilst driving up medical costs.

Global Health and Poverty

As noted previously, poverty and human security are intricately linked. The relationship
is also strong in the health aspects of human security. The relationship between poverty
and health is not limited to the effects of conflict but is more general in nature. This
relationship can be expanded beyond the two vulnerable populations of women and
children. The link between poverty and health is straightforward: ‘Poverty and infectious
diseases are fellow travellers—each feeding on the other. The poor are at a higher risk of
infectious disease, and sickness can deepen poverty, creating a vicious cycle of illness
and poverty’ (Ogata and Sen, 2003, 99). The poor are also at an increased risk for
non-communicable and ‘lifestyle’ diseases such as diabetes, cancer, and heart disease
due to poor diet and lack of exercise. The impact and role of poverty are also broader,
with some even suggesting that human security could be measured as the number of
years lived outside of generalised poverty (King and Murray 2001).
Poverty can be dissected along five capability lines: economic, human, political,
sociocultural, and protective (OECD, 2001: 38). Thus, poverty is not just about finances;
it is a holistic concept that taps into the dimensions of a sustainable and fulfilling life.
The linkage between poverty and health is through the line of human capabilities, where
human capabilities is based on health, education, nutrition, clean water and shelter. In
general, poorer people suffer from more preventable disease and typically die at a
younger age. Globally, poor people carry a heavier burden of disease than wealthier
people (OECD and WHO 2003, 19). Disease also negatively affects work production and
thus in the long term also hinders efforts aimed at poverty reduction (OECD 2001, 38).
Whilst small-scale work interruptions are part of the normal human condition, chronic
health problems, such as lifestyle diseases, and sudden outbreaks, such as Ebola, disrupt
long-term economic stability at the individual and national levels. In this sense disease
has a spiralling relationship with poverty: whilst poverty affects the onset of disease, it is
also true that disease reinforces the stranglehold that poverty has on people (OECD and
WHO 2003, 19).
Infectious diseases can exacerbate poverty in an underdeveloped region if an outbreak
occurs. Depending on the type of outbreak, individuals may not have the capacity to
work to pay for medical treatment. More drastically, if the parent who provides finances
for a family contracts a disease, the family will be forced to find other means of support
or risk falling into the cycle of poverty. Ogata and Sen elaborate on this relationship and
note that if this situation evolves in a family setting, ‘families are forced to sell their land,
tools and other productive assets, to borrow money from relatives and friends and to go
into debt to money-lenders. These strains continue even after death . . . health emergen-
cies . . . can precipitate a vicious downward spiral of sickness, compulsory spending,
asset depletion and impoverishment’ (2003, 100). Moreover, even national economies
 Global Health and Human Security   155

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

Global Health and Infectious Diseases

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

epidemics, the general population may perceive a high level of risk from being near the
epidemic and seek to flee or to take other defensive measures.
Whilst infectious diseases can affect or exacerbate pre-existing elements of poverty,
chronic non-infectious diseases have become more prevalent across the globe and can trap
people in a cycle of poverty. ‘Lifestyle’ diseases such as stroke, cancer, diabetes, and obesity
all take a personal and national toll. More than fifteen million deaths globally in 2015 can be
attributed to heart disease and stroke, with the costs of treating these diseases rising person-
ally and nationally (WHO 2017). When individuals are unable to work due to a lifestyle dis-
ease condition, the family suffers from financial constraints that limit the ability to pay for
medical treatment. Whilst these diseases have been more prevalent in developed countries,
economic development has brought these conditions to developing countries, which often
lack the public health infrastructure to contend with them. Thus, the disease burden for
lifestyle diseases is on a trajectory for the developed and developing worlds to converge.
Chronic, long-term epidemics, however, are more complicated in terms of the type of
responses they elicit from states and the population. Chronic epidemics are character-
ised by several factors: a wide geographic area is affected, many people are afflicted, and
the epidemics can last an indefinite period. Whilst the number of people affected may be
substantial within a geographic territory, the policy and social response to the epidemic
may be anaemic, and in chronic epidemic situations people may go about their lives
without much concern for the problem. A combination of reasons may account for the
seemingly sanguine response. Some people who live in what could be termed threaten-
ing environments may resign themselves to the idea that there is little, if anything, they
can do about the lingering threat. They live with the threat, but they try not to let it dis-
rupt their day-to-day lives. In part, people engage in a process of adaptation that allows
them to coexist with the health dangers they may face daily. At the same time, people
may also adopt a minimalist risk approach, believing that they will not be affected by the
problem, that it is a temporary situation, or that ‘it can’t happen to me’ (Rothbart 1970,
110). Whilst people may perceive the threat to others, they will minimise the threat to
themselves. These beliefs show a difference between one’s own perceived risk and the
perceived risk that one assigns to other people (Sjöberg 1998, 5). This process of ac­cept­
ance and adaptation is a key component of how disease moves from being an epidemic
to becoming endemic to a region.
The human security problems in both sudden and chronic epidemics are contained
within the state’s capacity to deal with an immediate emergency or crisis or long-term
health-related problems. Human security advocates have contextualised the inherent
dangers of sudden epidemics within the globalisation framework, emphasising that the
integration of populations can have devastating effects on large populations in a short
period. Such scenarios are not just the fodder for movie plots, but represent a prime
example of human security threats and extensions of the traditional security paradigm
that focuses on the security of territory, government, and populations. Today, what hap-
pens in one state may affect other states to varying degrees. Infectious disease outbreaks
have driven the point home to governments in many nations: what happens in your state
doesn’t always stay in your state.
 Global Health and Human Security   157

Conclusion

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

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

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 chapter 9

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

João Nunes

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

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

Critical Security Studies and

the Politics of Security

From the 1980s onwards, the field of security studies witnessed great effervescence when
some authors began to enquire into the meaning of security (Buzan 1983; Ullman 1983).
These contributions challenged the taken-for-granted assumptions of mainstream
strategic thinking, particularly its state-centric, Western-centric, militaristic, and mas-
culinist frames. Some scholars endeavoured to go beyond the state as the predominant
focus by looking at the security of individuals and societies in sectors other than the
military, in what amounted to the ‘widening’ and ‘deepening’ of the concept (Smith 2000).
This mirrored the growing influence of post-positivism in the discipline of International
Relations (IR), which came out of a broad concern with the nature and construction of
knowledge (Booth et al. 1996). For post-positivists, knowledge was not externally valid-
ated by reference to empirical ‘reality’, but rather part of an ensemble of interrelated the-
ories, knowledge claims, and social conditions of knowledge production (Lapid 1989). At
the same time, IR was also being influenced by Frankfurt School critical theorists, such
as Max Horkheimer and Jürgen Habermas, who, advancing the Marxist critique, saw
knowledge as socially and politically situated, that is, as deriving from particular polit-
ical interests. Knowledge was viewed as complicit in legitimizing and reproducing
forms of political organization predicated upon the domination of certain groups
(Hoffman 1987; Linklater 1996). The joint influence of post-positivism and Frankfurt
School Critical Theory gave a sense of coherence and purpose to emerging debates in
security studies. Security researchers began to recognize the field as an inherently political
site in which knowledge about security is produced and, more broadly, where security
practices are imagined and legitimized.
It is in this context that one can understand the emergence of CSS, a term first used in
Krause and Williams’s (1997a) Critical Security Studies: Concepts and Cases. This volume
set out to present an ‘epistemological shift in the way security is to be understood and
studied’ (Krause and Williams 1997b, 49). Since then CSS has questioned mainstream
security studies by broadening the range of issues (beyond the military sector) and con-
sidering other referents (besides the nation-state). It has also presented a radical departure
by approaching security as embedded in political processes. Ideas about security do
not derive from objective threats that can be observed ‘out there’ in the world. Instead,
CSS argues that they are connected with our assumptions about how political communi-
ties should be organized and the values we believe should be protected. One example of
this is the way in which, in the aftermath of the September 11, 2001 attacks, terrorism was
 Critical Security Studies and Global Health   163

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

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

The Critique of Health Security:

Securitization and Risk

The emergence of health as a global issue in the past few years is inextricably linked with
security. The 2001 anthrax attacks on the United States were a pivotal event that placed
health squarely within the post-9/11 context of broader security anxieties. For McInnes
and Lee (2012), security is one of the fundamental ‘frames’ that currently shape under-
standings of global health. As a result of the increasing salience of ‘health security’ in the
political discourse, security has assumed a central place in academic works on global
health. This is particularly true in the discipline of IR. The IR engagement with health
developed out of a concern with the impact of diseases on national security, particularly
state stability and the preparedness of armed forces—HIV/AIDS being one of the most
 Critical Security Studies and Global Health   165

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

concern’ (PHEIC) under the 2005 revision to the International Health Regulations.
PHEICs were declared by the World Health Organization (WHO) in relation to the
international spread of poliovirus in 2014, the 2014 Ebola outbreak in West Africa, and
the 2015 Zika virus disease outbreak. For Weir and Mykhalovskiy (2010, 126), PHEIC is
an important development in global health governance because it signifies a ‘fundamen-
tal shift from surveillance of the certain to vigilance of public health risk’ in the form of
uncertain and unexpected events. This shift has resulted in the use of resources in the
name of a precautionary principle, rather than in response to a clear and present health
problem. While in some cases a precautionary approach can be important to prevent
crises, it can also lead to the skewing of priorities to serve other agendas, such as media
or corporate interests.
The spread of the Zika virus is a good example of the pitfalls of a risk-based mentality.
In this case, the declaration of a PHEIC was not based on what was then known about
the virus. For the Emergency Committee advising the WHO secretary general on Zika,
the decision was taken on the basis of ‘what is not known about the clusters of micro-
cephaly, Guillain-Barré syndrome, and possibly other neurological defects’ (Heymann,
Hodgson, Sall et al. 2016, 719). In other words, the emergency was not the Zika virus in
itself, but rather the uncertain association between Zika and other disorders. For a few
months in 2016, Zika was the most prominent item on the global health agenda, com-
manding an enormous amount of media scrutiny and public attention. However, the
focus on Zika contributed to the neglect of other (interconnected and arguably more
pressing) health emergencies. In Brazil, the epicenter of the Zika outbreak, the Zika
epidemic is part of a broader and intractable problem with mosquito-borne diseases.
In 2016 the country reported 211,770 probable cases of Zika infection. What
remained largely unreported (at least in the global North) was the fact that in the same
period Brazil also reported around 1.5 million cases of dengue fever and at least 609
dengue-related deaths (Secretaria de Vigilância em Saúde—Ministério da Saúde 2016).
Also in 2016, Brazil reported 263,598 cases of chikungunya (with 159 confirmed deaths).
Both dengue and chikungunya are transmitted by the same mosquito that transmits
Zika. Yet the PHEIC declaration meant that all eyes were turned to the latter.
Thus, while in some cases securitization and the mobilization of risk may be useful to
draw attention to health problems, they can also contribute to obscuring other important
issues. Equally important is the quality of attention that is produced once one adopts
these prisms. Security framing is potentially conducive to a superficial engagement with
health problems. It helps to legitimize an emergency mode of response focused on con-
tainment and crisis management, which may narrow the range of policy options and
foreclose medium- and long-term interventions. The case of the recent Ebola outbreak
in West Africa reveals the extent to which framing an issue as a security problem—and
thus as a crisis needing an immediate fix—can lead to the privileging of short-term
measures and to the neglect of the long-standing structural problems that allow crises to
emerge (Nunes 2016).
In sum, a critical approach is committed to thoroughly examining the political impli-
cations of health security. This entails scrutinizing the specific policies enacted in the
 Critical Security Studies and Global Health   167

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

Health Insecurities:
Addressing Vulnerability

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

The pursuit of health security does not necessarily imply undemocratic measures or the
sacrifice of rights and liberties. When seen through the perspective of individual and
group experiences of insecurity, it can actually mean the opposite: the broadening of
democratic scrutiny on health policymaking, a more participatory debate about health
provision, and the expansion of rights. The critique of health security thus needs to be
able to consider situations in which the pursuit of security—or rather the alleviation of
insecurity of individuals and groups—is a good to be aimed for.
Thinking about security along these lines is key to one of the most important
approaches in CSS, namely security as emancipation. This approach distinguishes itself
by zooming in on insecurity as an experience of individuals. Insecurity has a bearing on
the inability of individuals to influence in a meaningful way the course of their lives.
Individuals who are more secure are able to think and act in matters pertaining to their
lives, free from social constraints such as physical aggression, political persecution, pov-
erty, or ill health, as well as from the broader structures and relations in which these con-
straints emerge. In this way, it becomes possible to approach health insecurity not
simply as the experience or threat of illness. Health issues can be considered matters of
security if they restrict in a decisive manner the ability of those involved—individuals,
families, and/or groups—to shape the course of their lives. Crucially then, this is not a
question of the seriousness of the illness, but of its ability to impact the lives of those
affected. For many people the simplest health problem can be a major constraint and
even a watershed; someone in a precarious job, for example, may run the risk of being
made redundant after calling in sick because of flu or an upset stomach, which in turn
may significantly affect their own quality life and that of their family.
This approach to the critique of health insecurity has at its heart the concept of vul-
nerability, inasmuch as it focuses on the identification and redressing of concrete health
vulnerabilities. What does it mean to ‘be vulnerable’ in the case of health? Vulnerability
can be defined as a group’s or an individual’s susceptibility to harm. In its most basic
sense—that is, as the possibility of being harmed—vulnerability is an intrinsic part of
being human, because we are all connected to and dependent upon others, in addition
to being exposed to natural hazards. As Butler (2004, 31) has argued, vulnerability fol-
lows from the inherently social and political nature of embodied life, from the fact that
we are ‘attached to others, at risk of losing those attachments, exposed to others, at risk
of violence by virtue of that exposure’. However, this does not mean that this fundamen-
tal bodily vulnerability is experienced in the same way by everyone. For example,
although we all require food and water throughout our lives, factors such as gender, age,
or disability may impact our specific experience of this vulnerability. Whereas in some
countries access to clean water is taken for granted and is as straightforward as turning
on a tap, in many regions of the world the procurement of safe water is an almost insur-
mountable task. Bodily vulnerability therefore intersects with the social, political, eco-
nomic, and environmental context in which individuals and groups find themselves.
Vulnerability may be an intrinsic part of what ‘being human’ means, but not everyone is
vulnerable in the same way.
Vulnerability becomes a matter of insecurity when it assumes a systematic character.
Vulnerable individuals or groups may be deemed insecure when they are structurally
 Critical Security Studies and Global Health   169

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

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

Critical Security and the

Politics of Global Health

Although the claim that ‘health is global’ has recently become part of the accepted nar-
rative in the wake of high-profile disease outbreaks (such as H1N1 ‘swine flu’, Ebola,
Zika, and the fear of an H5N1 ‘avian flu’ pandemic), global health is the result of a
long-term historical process (Brown, Cueto, and Fee 2006; Birn 2009; Cueto 2015).
Indeed, its genesis can be traced back to the 1851 International Sanitary Conferences
(Fidler 2005). Underlying ‘global health’ is the idea that globalization has brought
 Critical Security Studies and Global Health   171

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

which interests and agendas clash (Fassin 2012). The International Sanitary Conferences,
for example, were marked from the beginning by a fundamental concern with the pro-
tection of international trade. The underpinning purpose of these conferences was not
the protection of public health, but rather the definition of common measures that
would allow for the cross-border circulation of people and goods to be controlled. Such
control was based not simply on the restriction of movement, but more precisely on a
triage, that is, on the separation between ‘desirable’ and ‘undesirable’ people and goods.
In other words, security and economic concerns were closely intertwined in these early
efforts of international health cooperation (King 2002). This logic is still present today,
with global health governance being not an apolitical project, but rather revealing the
intersection of security, capitalism, and a liberal worldview. Assumptions of neutrality
frequently serve to obscure the fact that global health, since its inception and in its
contemporary forms, has been a site of exclusion, vulnerability, inequality, and the dis-
advantage of certain groups and regions.
A critical approach to global health is therefore concerned with identifying the polit-
ical structures and relations that underpin global health governance mechanisms, as
well as their ideological assumptions. Here, the conceptual and theoretical tools of CSS
are particularly useful, enabling an investigation into the processes through which
health-related ideas and practices are advanced, interpreted, justified, legitimized, and
contested. The securitization approach, and its emphasis on the intersubjective process
through which a health issue is presented as an existential threat demanding emergency
measures, is a good example of how a seemingly natural or uncontroversial narrative
can be brought into question. Even when presented in a straightforward manner—as in
the form of a ‘health security’ narrative—the meaning of global health is socially con-
structed, ambiguous, and therefore not fixed once and for all. CSS can help us engage
with the multiple arenas of signification that underpin global health discourses.
A critical approach to global health is also concerned with a second question, that of
exploring the political consequences of the processes through which health and disease
are made sense of at the global level. In other words, how do these processes impact the
definition of ‘necessary’ or ‘desirable’ policies? Given that concepts play an important
role in circumscribing the limits of the political imagination, investigating how global
health is framed is a springboard toward an examination of the context in which spe-
cific policies are defined and executed. Again, CSS can be useful in this regard. Not only
does it open fruitful avenues of research into the potentially dangerous implications of
certain policies, but it also provides a normative agenda for policy based on the core
concern of redressing health insecurities in the form of vulnerabilities.
A third way in which CSS is useful in a critical engagement with global health is by
opening the way to consider traditionally neglected issues. This may seem counterintui-
tive because ‘security’ is often associated with high-profile issues: problems that are
framed as urgent crises requiring prioritization and mobilization of resources. At first
glance, then, a security approach would seem ill-suited to engage with issues that fail to
reach the status of ‘threat’ and thereby garner attention and resources. Nonetheless,
the focus on the individual and group levels of insecurity, as well as the concern with
 Critical Security Studies and Global Health   173

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

Conclusion

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

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

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 chapter 10

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

Christian Enemark

A myriad of allergies, congenital conditions, physical injuries, mental health disorders,

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

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

Biosecurity as Biodefense:
A Security Dilemma

Global health is potentially diminished by any increase in the overall likelihood of

biological attacks occurring somewhere in the world. State-based efforts to defend
against biological attacks (biodefense) do not, for the most part, present a problem in
this regard. For example, accumulating medical supplies and upgrading hospitals’ cap­
acity to treat attack victims are generally not regarded by other states as worrisome
activities. However, an international political problem might arise when a government
undertakes biodefense activities for ‘threat assessment’ purposes, and here the essential
problem is one of offense/defense differentiation. One state’s activities, purportedly
aimed at affording protection against pathogenic microorganisms that are deliberately
disseminated, might be perceived by the government of another state as having an offen-
sive purpose. And if that suspicion occasioned similar activities (investigations into
offensive capabilities) to occur in that other state, the result could be a proliferation of
biological weapons and an increasing likelihood of biological attacks as each side con-
tinued to compete for technological advantage.
One state’s possession of particular technologies, or its conduct of particular activities,
might not in fact be intended to threaten another state. But when such a fact is difficult
 Biosecurity and the Risk to Global Health   181

to verify, a state that is uncertain of another’s capabilities and intentions is liable to

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

serve a genuine defensive purpose, such as informing the design or improvement of

protective bodysuits and devices for detecting airborne microorganisms. It is also the
case, however, that such investigation could guide the planning and execution of a
biological attack. As noted in a 1998 US government report: ‘Stabilization and disper-
sion [research] are proliferation concerns because these technologies increase the
efficacy of biological [warfare] agents’ (US Department of Defense 1998). At around the
time this report was written, the US government was conducting a number of secret bio-
defense experiments of a kind that, after their revelation by the New York Times in 2001,
raised questions about whether they were geared more toward offense than defense.
From 1997 to 2000, for example, Project Clear Vision (sponsored by the Central
Intelligence Agency) involved the building and testing of a Soviet-model ‘bomblet’ for
dispersing bacteria (Miller et al. 2001a). A number of these bomblets were reportedly
filled with simulant pathogens (unable to cause disease) and tested for their dissemin-
ation characteristics and reliability under various atmospheric conditions. Experiments
in a wind tunnel revealed how the bomblets would fall on targets after being released
from a warhead (Miller et al. 2001b, 295). From the perspective of an outside observer,
was this an instance of US biodefense activities bringing the ‘biological’ overly close to
the ‘weapon’?
More recently, biodefense research carried out by the US Army has included the use
of various uncontained spaces to explore possibilities for dispersal of biological material.
For example, among the ‘tunnel dissemination systems’ at the army’s Dugway Proving
Ground in Utah, the Joint Ambient Breeze Tunnel features an ‘overhead, four-zone
Sono-Tek nozzle array’, with maneuverable dissemination carts providing for ‘precision
set-up of aerosol cloud generation’ (US Army 2012, 44). Here, ‘[p]ortable liquid and dry
dissemination systems may be operated for specific tests to replicate an attack (e.g., covert
backpack attack), including electric Micronair sprayers and E2 sprayers, Skil® blowers,
and puff disseminators’ (US Army 2012, 44). And when a Skil® blower is used to release
‘5 to 10 grams’ of a ‘dry powder simulant’, it creates ‘a concentration of 5,000 to 20,000
particles per liter inside a tunnel’ (US Army 2012, 44). Biodefense work at Dugway’s
Lothar Salomon Test Facility includes the use of ‘simulants’ in ‘outdoor studies’ to
‘develop/validate aerosol particle dispersion models to enhance coun­ ter­meas­ ure
response’ (United States of America 2016, 42). For example, simulants used in a 2005
field trial of the Joint Biological Standoff Detection System included a ‘[d]ry killed vac-
cine strain of Bacillus anthracis [anthrax]’ and a ‘[w]et killed vaccine strain . . . of Yersinia
pestis [plague]’ (Buteau et al. 2007, 11). The trial included one late-night dissemination of
20 grams of dry anthrax simulant at a ‘target range’ of 1.2 km and another at a range of
2.6 km, and disseminations of 3.5 liters and 7.0 liters of plague simulant at a target range
of 1.2 km and 7.0 km, respectively (Buteau et al. 2007, 37–40).
The latter form of experimentation is presumably driven by two assumptions: first,
that the systems being tested would be able to detect the dispersal of living bacteria as
well as dead ones; and second, that the dispersal mechanisms used to challenge those
systems would deliver both kinds of material to the target in the same way. It follows that
the operator of the dispersal mechanisms would only need to fill them with real pathogens
 Biosecurity and the Risk to Global Health   183

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

Biosecurity as Information Security:

Censoring the Findings of
Pathogen Research

A large-scale biodefense enterprise, even if it is primarily directed toward defending

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

more dangerous could enable and encourage the use of that information for a harmful
purpose (such as a biological attack). On the other hand, making such findings widely
available to other scientists might vitally assist the development of new or improved
measures for controlling the relevant infectious disease. To the extent that sharing
research findings with other scientists would be beneficial to public health, there is
a technology-transfer imperative. But if there are risks associated with such sharing,
a government might also act upon a perceived non-proliferation imperative to
­prevent this.
The dilemma is well illustrated by the controversy surrounding the publication in
2012 of certain findings from research into the potential of H5N1 avian influenza
(bird flu) to become more transmissible (Herfst et al. 2012). At the time of writing, there
had been 860 confirmed human cases of H5N1 avian influenza in sixteen countries since
2003, including 454 deaths (a global average case-fatality rate of around 53 percent)
(World Health Organization 2017). The continued circulation of H5N1 in poultry, and
occasional infections of humans, has enabled ongoing viral evolution, and a key ques-
tion for scientists has been whether this could eventually lead to the emergence among
the human population of a virus with pandemic potential. Such a virus would be able to
spread through the air between humans, and it would present a serious danger to public
health globally, so some influenza researchers have been interested to discover which
genetic mutations might allow H5N1 to do this. Ron Fouchier at the Erasmus Medical
Centre (EMC) in Rotterdam, the Netherlands, was one of many scientists funded by the
US National Institutes of Health to conduct experiments to investigate how H5N1 might
evolve to acquire the ability to spread from person to person (Maher 2012, 432). In
September 2011 Fouchier announced a breakthrough: using genetic engineering
techniques, he and his research team had succeeded in causing the mutation of H5N1
into a form directly transmissible (through the air) between animals (Specter 2011). A
ferret’s respiratory system closely resembles that of a human, and ferret-to-ferret
transmission of influenza virus is generally assumed to demonstrate human-to-human
transmissibility. Thus it seemed that a new and presumably pandemic virus had
emerged not through natural evolutionary processes, but rather as a result of human
experimentation.
A written account of this discovery (including a description of how it was achieved)
was made ready for submission to the highly respected US-based journal Science. Soon
afterward, however, the Dutch government took an extraordinary action, requiring
Fouchier to apply for and be granted permission to ‘export’ his team’s research findings
beyond the European Union (EU) (Enserink 2012a). The legal basis for this intervention
was EU Council Regulation 428/2009, which provides a framework for EU states to
control exports of dual-use technology to non-EU states (European Union 2009). On
April 27, 2012, the Dutch minister for agriculture and foreign trade announced his
decision to allow the export of H5N1 technology to the editor of Science in this instance,
stating that he had ‘weighed all of the benefits and risks of publication of the avian
influenza research’ (Enserink 2012b). It is not clear exactly how the Dutch government
arrived at and justified its decision. Did it do the right thing in allowing publication to
 Biosecurity and the Risk to Global Health   185

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

We have to be prepared for such viruses to emerge in the wild. If we would detect
these viruses out in the field, then we could go out to outbreak areas and try to
eradicate the virus and prevent a pandemic from happening. If that would fail, then
we would still be in a good position to, ahead of that pandemic, evaluate our vaccines
and anti-viral drugs and therefore gain months of time if a pandemic would hit and
therefore we would be able to handle it better. (Fowler 2012)

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

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

Biosecurity as Global Health Security:

Prioritizing Risks and Responses

Beyond biodefense and censorship carried out by governments individually, bi­o­se­cur­ity

can also be a cooperative practice engaged in by multiple governments for the sake of
populations that are collectively vulnerable to infectious diseases. Here too, difficulties
can arise when priority status for a narrow range of disease risks (including the risk of
biological attacks) is institutionalized by international health-governance arrangements
for ‘global health security’. The challenge is to achieve extra protection for populations
worldwide against prioritized disease risks without thereby neglecting other serious
health burdens and health system problems in particular parts of the world. At the heart
of this challenge is the tension between prioritization policies that promise to satisfy the
greatest quantum of human need and those that are most likely to be politically feasible.
David Stuckler and Martin McKee (2008) have observed that policymakers use different
metaphors for global health, each of which results in the term meaning something other
than the perfect health and complete well-being of all people everywhere. In accordance
with the metaphor of ‘global health as public health’, for example, attention and resources
are directed toward ‘decreas[ing] the worldwide burden of disease, with priority given
to those risk factors and diseases that make the greatest contribution to this burden’
(96). This may be contrasted with the ‘global health as security’ metaphor, according to
which health policy seeks to ‘protect one’s own [national] population, focusing mainly
on communicable diseases that threaten this population’ (Stuckler and McKee 2008,
96). Emphasizing some infectious disease risks in pursuit of an agenda of global health
security seems more likely to attract political and financial commitments from wealthy
governments that are fearful of those diseases. However, such an arrangement could
generate less public health benefit throughout the world than would one whose broader
humanitarian rationale might be politically more difficult to support over the long term.
In 2007 a World Health Organization (WHO) report defined ‘global public health
security’ as ‘the activities required, both proactive and reactive, to minimize vulnerability
to acute public health events that endanger the collective health of populations living
across geographical regions and international boundaries’ (5). This definition immedi-
ately brings to mind outbreaks of diseases that are both deadly and fast spreading, like
SARS and pandemic influenza. The implication of such framing is that problems of a
non-‘acute’ nature are excluded from the agenda of global health security, even though
the sum of such problems accounts for the greater part of health need throughout the
 Biosecurity and the Risk to Global Health   187

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

The principal benefit to be derived from global surveillance of influenza viruses is an

early warning to all governments of the emergence, anywhere in the world, of a virus
with pandemic properties. Such a warning of the commencement of human-to-human
viral transmission is valuable because it supposedly allows everyone more time to, if
possible, organize and implement a response. However, the value of a warning is
potentially diminished by the continued inability of many countries to secure an
adequate supply of pandemic influenza vaccines. A fundamental and persistent
problem is that the total amount of influenza vaccine that can be produced annually is
far from enough to protect everyone everywhere. The availability of a pandemic vaccine
is not truly global, despite pandemic influenza having acquired priority status as a disease
that poses a global health security risk. Therefore, only the wealthiest of countries, whose
governments have pre-ordered doses of vaccine, are able to take full advantage of global
influenza surveillance as a biosecurity practice. In mid-2009, for example, the United
States had already ordered 40 million doses of vaccine against the pandemic H1N1 swine
flu virus; the United Kingdom had ordered 90 million and France 50 million (Hayden
2009). Six months into that pandemic, only 534 million doses were available worldwide,
and after one year there were 1.3 billion (Stöhr 2014). And so for the duration of the
pandemic, a large majority of the world’s population (including many in countries with
high incidence of infection) remained unprotected by vaccination.
That swine flu pandemic turned out to be a mild one, but concerns about vaccine
availability had been raised earlier by the governments of some developing countries
fearful of the pandemic potential of H5N1 bird flu. In January 2007 the Indonesian
government drew attention to its concerns by abruptly withholding samples of H5N1
virus from the WHO Global Influenza Surveillance Network. At that time Indonesia
was continuing to experience many more cases of human H5N1 infection than any other
country. Therefore Indonesia was a vital source of information on that influenza virus’s
properties and whether it might be mutating into a pandemic form. Indonesia’s health
minister, Siti Supari, used this fact to apply political pressure to further her country’s
health interests. At a meeting with WHO officials in March 2007, she sought assurances
that Indonesia would receive vaccines if a pandemic occurred, and she described the
global vaccine supply scheme then in place as ‘more dangerous than the threat of an
H5N1 pandemic itself ’ (Normile 2007). Assistant director-general David Heymann of
WHO accused Indonesia of ‘putting the public health security of the whole world at risk’
by not sharing influenza virus surveillance data (Roos 2007). However, what Indonesia
was essentially claiming was that poorer countries were already experiencing a high
degree of health insecurity, and that cooperation with influenza researchers worldwide
seemed pointless if those countries were unable to benefit from the vaccines that result
from that cooperation. This claim thus presented a fundamental challenge to the practice
of biosecurity qua global health security; achieving protection against selected infec-
tious disease risks would only happen if there was international cooperation on disease
surveillance.
In formal recognition of the concern represented by Indonesia’s drastic action, four
years later the World Health Assembly adopted the Pandemic Influenza Preparedness
 Biosecurity and the Risk to Global Health   189

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

Biosecurity as Border Security:

Transnational Contagion and
Travel Restrictions

The previous section discussed an international-level approach to biosecurity that is

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

comes to infectious diseases, and because human bodies can harbor disease-causing
microorganisms, resisting a deadly and fearsome contagion can sometimes seem to
require keeping people out. Border-based, migration-related biosecurity measures can
thus serve a useful domestic political purpose in assuaging the anxiety of populations
inside a given territory. However, preventing inward (and outward) travel is a measure
that potentially does more harm than good, especially if an effective response to a
disease outbreak is critically dependent on the free flow of people across inter-
national borders.
A key principle since the international health-governance arrangements of the
nineteenth century, which is repeated in the contemporary IHRs, is that states responding
to the spread of disease must ‘avoid unnecessary interference with international traffic
and trade’ (World Health Organization 2008, 10). The rationale for this is that exces-
sively severe restrictions on cross-border travel can exacerbate rather than mitigate the
adverse impact of a transnational disease outbreak. Moreover, in today’s highly inter-
connected world, in which microorganisms are as mobile as their human hosts, it is
widely acknowledged that the policing of borders to prevent microbial incursions is
often futile. Even so, circumstances may arise in which pharmaceutical resources
(antibiotics, vaccines, etc.) are unavailable or insufficient. In these cases, a conscientious
government might decide that there is no alternative but to adopt the centuries-old,
non-pharmaceutical approach of containing contagion by limiting human movement
and interaction (‘social distancing’). This was the case when, in 2014, the governments of
Guinea, Liberia, and Sierra Leone confronted the largest-ever outbreak of Ebola, a
disease that could not at the time be prevented or treated by any drug. The governments
of some other countries, within and beyond West Africa, responded by unilaterally
banning travel to and from the outbreak zone, hoping that extreme exclusion would
prevent further contagion.
This biosecurity practice, however, turned out to be counterproductive to defeating
the Ebola outbreak. The Ebola virus does not transmit easily, so it is relatively easy to
contain using basic infection-control measures. Therefore, in the absence of a safe and
effective vaccine or therapeutic drug, the best approach to Ebola relief in West Africa
was to insert a large number of capable, adequately supplied medical personnel into
the situation to treat illness and prevent infection. To that end, in late July 2014 WHO
director-general Margaret Chan announced a $US100 million plan to send more medical
experts and supplies to the region (Nossiter and Grady 2014). Such an approach was
stymied, however, by unilateral decisions by some governments to restrict or prohibit
travel to and from the worst-affected countries.
On August 8, 2014, when WHO declared the Ebola outbreak to be a ‘public health
emergency of international concern’, its advice to all states was: ‘There should be no
general ban on international travel’ (World Health Organization 2014a). By this time,
however, a number of countries were attempting to establish international border-based
obstacles to the spread of Ebola. Nigeria, Kenya, Ivory Coast, and Senegal banned all
travel to and from Guinea, Liberia, and Sierra Leone (Anonymous 2014a; Anonymous
2014b; AFP 2014). Air France suspended flights to Sierra Leone on the recommendation
 Biosecurity and the Risk to Global Health   191

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

Conclusion

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

biological attacks. When biosecurity means information security, a decision to prevent

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

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 chapter 11

Milita ry Assista nce

du r i ng H e a lth
Em ergencies

Adam Kamradt-Scott
and Frank Smith

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

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

Background

Historians have long been aware of the devastating impact that poor health and disease
outbreaks can have on military readiness and operations. Thucydides, for example, fam-
ously documented the damage wrought by an unknown plague on the people of Athens
during the Peloponnesian War. Ever since, military historians have paid attention to the
adverse impacts of disease, including the collapse of Alexander the Great’s conquest
after he died from malaria (Cunha 2004), the decimation of indigenous populations
by smallpox during the European conquest of the Americas (Diamond 1999), and the
widespread death of soldiers from dysentery during the Napoleonic Wars (Cook 2001).
Militaries have also paid attention to preventing disease through sanitation, treatment,
research and development, and the formation of dedicated military medical services
(Atenstaedt 2010). During the American Revolution, for instance, General George
Washington ordered the Continental Army inoculated against the ravages of smallpox,
which “must surely rank among his most important decisions of the war” (Fenn 2001,
134). Similarly, penicillin was first mass produced by the United States in preparation for
the invasion of Normandy during World War II (Smith 2014a).
Historically, the primary mission of military medical services was to treat combatants
injured during fighting. Over time, however, such assistance has been interpreted more
broadly, and it is now included as a standard component of stability and reconstruction
operations, as well as HADR (Neuhaus 2008; Gordon 2011) and even health or science
diplomacy (Smith 2014b). Offering this assistance has in turn helped militaries them-
selves in at least two ways. First, in strengthening force protection, armed forces have
benefited from improved health both at home and when deployed abroad (Gibson 2013;
Ingham 2014). Second, military medical services and scientific exchange programmes
have created opportunities to build goodwill and improve military-to-military relations
abroad (Engstrom 2013).
Though the fact is sometimes unacknowledged, the military has also helped
advance public health and medicine at large. For instance, US military research on
vaccines for yellow fever helped pioneer the practice of informed consent, which
­subsequently became a standard requirement in clinical interventions (McManus
 Military Assistance during Health Emergencies   199

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

support these concerns (Katz and Wright 2004). Even inside the military, there is
re­sist­ance to ‘military operations other than war’ (MOOTWs), as well as other activities
such as medical research and development. Some military personnel are sceptical of
supporting capabilities that differ from more conventional war-fighting activities,
particularly when confronted with cuts to defense spending. Others—including some
military medical professionals—have more nuanced concerns, arguing that interventions
such as Medical Civic Action Programmes (MEDCAPs) may be too short-term to have
lasting benefits for the populations they are intended to help, or that they may inadvert-
ently undermine local health services (Gordon 2010, 2014).
Although the conditions in which military medical assistance is appropriate have not
been sufficiently specified, there are nonetheless a number of broad parameters for
military involvement during health emergencies that have been enshrined in protocols
such as the ‘Oslo Guidelines’ (Tatham and Rietjens 2016). One common premise is that
the military should only ever be called upon as a ‘last resort’ (Anderson and Nevin 2016).
Yet despite this stated policy preference, ambiguity remains about the actual meaning of
‘last resort’ (Tatham and Rietjens 2016). There are also potential opportunity costs—in
lives lost—of waiting to cross this vague threshold. As a result, confusion persists over
when it is legitimate or appropriate to engage military forces, and similarly, over what
types of health activities—if any—they should undertake.
However, at least two analytical distinctions can be drawn when surveying military
involvement. The first is whether a given emergency is ‘natural’ or ‘complex’. Few
humanitarian organizations would contest the idea that militaries can play an important
role in the aftermath of a natural disaster. Most militaries would acknowledge the same.
Indeed, since the end of the Cold War several militaries from high-income countries
have assumed prominent roles in international disaster response and recovery. Among
other examples, Russian military aircraft were used to transport humanitarian aid to
China following the 2008 Sichuan earthquake (Licina 2012). Similarly, the US military
airlifted humanitarian aid, healthcare workers, and patients after the 2010 earthquake in
Pakistan and after the 2014 typhoon in the Philippines (Lum and Margesson 2014;
Madiwale and Virk 2011). The US and Australian militaries also deployed personnel and
assets to Indonesia following the 2004 tsunami (Byleveld et al. 2005). In each of these
cases, domestic military personnel were already on the ground, and for many low- and
middle-income countries, their militaries are the only national ‘emergency services’ that
are available. Thus, in the context of natural emergencies, military medical assistance
may even be described as ‘the backbone of disaster medical relief ’ (Liu et al. 2014, 33).
A different set of circumstances arises when the environment is post-conflict, or,
relatedly, a ‘complex emergency’ in which some form of fighting is ongoing. When
armed forces have served previously as belligerents, or when the security environment
is transitional, civil-military cooperation understandably becomes much more fraught.
The risk to humanitarian workers may in turn increase if they are perceived to be associ-
ated with armed forces (Winslow 2002; Wilson 2009). In these circumstances, rather
than overt cooperation, an alternative approach may be either ‘co-ordination’ between
humanitarian organizations and military forces that operate independently but regularly
 Military Assistance during Health Emergencies   201

liaise to prevent duplication of effort, or ‘co-existence’, whereby these organizations

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

Brazil and Zika

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

the risk to athletes and visitors, the Brazilian government took the unprecedented step
of deploying over 220,000 military personnel in a campaign to eliminate mosquito
breeding environments, distribute educational pamphlets, and apply larvicides in the
areas of immediate concern (Szklarz 2016). Some commentators suggested that using
the armed forces in what was essentially a public health campaign reflected a broader
narrative the government had been promoting of ‘Brazil as a responsible global leader’,
with the deployment of military personnel (including former peacekeepers) exemplify-
ing its commitment to humanitarian ideals (de Oliveira 2016). By comparison, others
have argued that this deployment reflected chronic underinvestment in the Brazilian
healthcare system, which was overstretched and thus unable to respond with a purely
civilian public health intervention (Hennigan 2016).
Either way, the decision to deploy the Brazilian military to fight Zika was a political
and potentially high-risk strategy. The relationship between civilian authorities and the
military in Brazil has a strained history, given military interference in Brazilian politics
that culminated in a military coup in 1964 (Stepan 1971). Civil-military relations have
improved since then, although financial crises, disputes over salary levels, and reduc-
tions in military personnel throughout the 1990s added to the tension (Sotomayer
2013). At the same time, Brazil increasingly used its military in non-war-fighting con-
texts, and during the 2000s the government launched a campaign to ‘redefine its global
identity’ by committing to international peacekeeping missions (Sotomayer 2013, 55).
Reportedly, its first goal was to modernize the army, since soldiers deployed on these
missions would purportedly gain an appreciation for the rule of law and conflict preven-
tion, and to ‘democratize’ the military mindset. This experience could thereby help the
military meet its constitutional obligations, which include assisting in natural emergen-
cies and combating violent threats to public safety (Cepik and Bertol 2016). A second
goal was to demonstrate commitment to international peacekeeping missions and thus
strengthen Brazil’s case for a permanent seat on the United Nations Security Council
(Sotomayer 2013).
Along with increased peacekeeping, Brazil also diversified the types of missions and
personnel that it deployed, which over time included medical teams (Cavalcante 2010).
After playing a small role in UNTAET in Timor Leste, Brazil significantly increased its
commitment to assist the UN mission to Haiti, Mission des Nations Unies pour la stabil­
ization en Haïti (MINUSTAH), in 2004 (Kenkel 2010). According to Arturo Sotomayer
(2013), however, the ‘pacification’ skills that the Brazilian military learned in Haiti were
then reused in 2010 to clear slums in Rio de Janeiro (favelas) of drug traffickers and gangs.
A similar strategy was employed again in 2014 in preparation for Brazil’s hosting of the
World Cup (Sotomayer 2013, 88; Harig 2015). These domestic deployments were met
with resistance, increasing the potential risks associated with the subsequent decision to
deploy the military to help halt the spread of Zika. The military’s heavy-handedness in
2010 resulted in summary executions, martial law, and ‘tanks blasting through impro-
vised roadblocks’ (Gaffney 2012, 75). Violence against the military escalated when the
armed forces were used to pacify the Rio favelas again in 2014 (Watts 2014).
 Military Assistance during Health Emergencies   203

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

Ebola and the International

Response in West Africa

To date, the single largest mobilization of military assets—in terms of personnel and
hardware—solely to provide emergency health assistance was in response to the 2014
Ebola outbreak. In total, more than five thousand foreign military personnel from the
United States, the United Kingdom, China, Canada, Germany, France, and the African
Union were deployed to help the governments of Liberia, Sierra Leone, and Guinea
eliminate this disease (Kamradt-Scott et al. 2015). In addition, domestic military forces
in these three countries were also engaged in helping civilian authorities and preventing
further Ebola-related morbidity and mortality (Kamradt-Scott et al. 2015).
This deployment of military personnel has generally been hailed as a success, even to
the point of suggesting that it was instrumental in containing this outbreak. The West
African outbreak was traced back to Guinea in December 2013, having started in a
village neighbouring Liberia and Sierra Leone, but it was only identified as an outbreak
of Ebola Virus Disease in March 2014. The virus spread across West Africa (principally
Guinea, Liberia, and Sierra Leone, with a small number of cases in Nigeria), most not-
ably in major cities, where it inflicted considerable morbidity and mortality. According
to official figures, more than 28,000 people became infected and over 11,300 died (WHO
2016), although it is generally accepted the actual number of cases may have been much
higher. This outbreak was eventually contained and declared officially over in January
2016, but there have been a number of isolated cases of survivors subsequently infecting
close contacts (otherwise described as ‘flare-ups’).
Due to the increasingly high prevalence of Ebola patients in September 2014, MSF
made the highly unusual move of requesting foreign military assistance in West Africa.
As early as August 2014, however, US and Chinese military officials were already in
affected countries undertaking their own assessments, providing technical expertise,
and—in the case of China—rendering some medical care (Fan et al. 2015). By October
2014, advance military teams from several countries arrived in West Africa to establish
their respective bases of operations. By December 2014, FMA had reached its peak
across the region. The US and UK military forces were deployed to Liberia and Sierra
Leone, respectively, reflecting their historical ties as well as post-conflict reconstruction
and military cooperation (Nevin and Anderson 2016, Kamradt-Scott et al. 2015). Other
military forces, such as China’s People’s Liberation Army (PLA), established operations
across all three of the worst-affected countries (Taylor 2015). The most common roles
performed by FMA during this outbreak were training local healthcare workers and
building Ebola treatment units (ETUs). Beyond this, the functions and activities that
each military performed varied considerably. For example, whereas the UK and Chinese
militaries established medical units that were staffed by military physicians and nurses
to care for suspected or confirmed Ebola patients, the US military was prohibited
from offering medical care. The US military was also prohibited (as a matter of policy)
 Military Assistance during Health Emergencies   205

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

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

Polio Vaccination in Pakistan

Pakistan is one of two remaining countries where polio currently remains endemic.
Routine immunization against poliovirus began in Pakistan in 1978. These efforts were
expanded with the launch of the World Health Organization’s (WHO) Global Polio
Eradication Initiative in 1988. But it was not until 1994 that Pakistan’s government imple-
mented a systematic campaign that included regular surveillance, house-to-house visits,
national immunization days, and ‘supplementary’ immunization initiatives during agreed
upon ceasefires in conflict-affected areas (Hussain et al. 2016; Munir and Rehman 2016).
The prospects for polio eradication in Pakistan remain fraught to this day, in large part
due to ongoing security concerns.
Between 1998 and 2012, polio eradication workers operated in Pakistan without sig-
nificant interference or threat of harm. In 2012, however, the Taliban imposed a ban on
polio vaccination in the Federally Administered Tribal Areas (FATA). This vaccination
ban is widely believed to have been imposed because of revelations that the US Central
Intelligence Agency (CIA) used a hepatitis B vaccination campaign to help locate and
ultimately kill Osama bin Laden (Ahmed 2015). Following the ban, violent attacks
against polio eradication workers escalated, in which more than eighty personnel were
killed, and causing the campaign to be officially suspended throughout the FATA in
2014 (Hussain et al. 2016; Kakalia and Karrar 2016; Gill 2016). Attacks against people
who had been vaccinated increased as well, with individuals who received the vaccine
reportedly being subject to public beating, humiliation, and even abduction (Munir and
Rehman 2016). In response to this violence, Pakistan initially deployed the police force
 Military Assistance during Health Emergencies   207

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

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

Tailgate Medicine in Iraq

and Afghanistan

‘Tailgate medicine’, as the name implies, is medical care dispensed from the back of a
truck or a similar temporary facility (McInnes and Rushton 2012; Lougee 2007). The US
military in particular has a long history of providing this kind of temporary care through
MEDCAPs. For example, these programmes were used to varying degrees during the
1950s in the Philippines, in the 1960s in Vietnam, and in the 2000s in Iraq and Afghanistan
(Baker 2007). MEDCAPs have also been used during peacetime to provide medical care
to rural and/or remote communities in low-income countries that would not otherwise
have ready access to these services (Bouchat 2015). For instance, the hospital ships USNS
Comfort and Mercy are often deployed for peacetime operations (Waller et al. 2011). Still,
the temporary and ad hoc nature of this assistance remains the same.
Tailgate medicine was a notable and common practice in the Afghanistan and Iraq
Wars. In both countries, coalition forces—namely the Multi-National Force–Iraq
(MNF–I) and the International Security Assistance Force (ISAF) in Afghanistan—
engaged in MEDCAPs. These programmes were often part of stability or counterinsur-
gency operations designed to ‘win hearts and minds’, gather intelligence, and promote
other military or political objectives (Malish, Scott, and Rasheed 2006; Baker 2007;
Olsthoorn and Bollen 2013). In this respect, military medical personnel and the services
they provided were intended to achieve some tactical, operational, or strategic benefit.
While perhaps related, the health outcomes of local populations were implicitly of sec-
ondary importance. As Thompson (2008, 1) observed in Afghanistan, for instance,
‘Medical interventions are an important component of a diplomatic strategy to regain
moral authority for U.S. actions, regain the trust of moderate Muslims, and deny terror-
ists and religious extremists unencumbered access to safe harbor in ungoverned spaces’.
Similar motivations were behind MEDCAPs in Iraq, which appeared to provide ad hoc
solutions to health emergencies in the absence of a more robust policy for rebuilding of
the country (McInnes and Rushton 2014).
 Military Assistance during Health Emergencies   209

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

Military medical activity undertaken for perceived short-term gains may undermine
the military mission in the medium to longer term, particularly in counter-insurgency
(COIN) operations, by reducing confidence among the indigenous population in
their government’s ability to provide these essential services.

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

partners to help improve the sustainability of these medical interventions (Alderman,

Christensen, and Crawford 2010). Similar arguments and evidence also support greater
communication and collaboration among the military, international organizations, and
NGOs (Pueschel 2010; Miles and Malone 2013). Improvement along these lines may in
turn enhance the health outcomes associated with this kind of military medicine.

Conclusion

Militaries have long been called upon to provide health-related assistance. The health
emergencies that they may respond to can vary, and the identities and functions of the
militaries involved can vary as well. While the history of military assistance is long and
complex, this brief survey provides an analytical framework and comparative context to
help understand the relationship between military forces and health emergencies in
the past, present, and future. However, we still lack a robust framework to evaluate how
and when militaries should be called upon to assist, including the types of activity it is
reasonable to expect them to perform. As part of our contribution to developing such a
framework, we suggest that it is useful to distinguish natural disasters and disease out-
breaks from complex emergencies that include armed conflict. Foreign versus domestic
military assistance is another critical distinction.
Through case studies of Brazil’s fight against Zika, the outbreak of Ebola in West
Africa, polio vaccination in Pakistan, and MEDCAPs in Iraq and Afghanistan, this
chapter has considered some of the concerns and controversies that surround military
health assistance. These include the ‘militarization’ of humanitarian assistance, the
‘blurring’ or confusion of humanitarian and military roles, short- versus long-term
health objectives and outcomes, and the ever-present political interests involved in local
and global public health. In addition, we have noted some of the ways that military
assistance may have made positive contributions in each of these cases. While noting
these contributions and concerns, we have sought to avoid the common tendency to
draw stark moral or normative conclusions about the appropriateness of military assist-
ance. Granted, we do suggest that the analysis of such assistance should consider the
alternatives available, as well as the impact on those communities that stand to be most
directly affected. Yet this kind of analysis is warranted given the significance—for better
or worse—of military involvement. More research is also justified because, as in the
past, it is likely that we will continue to witness military personnel being deployed dur-
ing future emergencies and crises to render healthcare.
Until this further work is undertaken, consensus on where and under what circum-
stances military assistance in health emergencies is appropriate will continue to elude
us. While this may conceivably be welcomed by some, there are times when the partici-
pation of armed forces in an emergency can provide explicit benefits, particularly with
regard to securing the operational environment. Moreover, where human lives are at
stake, governments may be tempted to utilize whatever resources they have at their
 Military Assistance during Health Emergencies   211

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

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 chapter 12

Gl oba l He a lth a n d
I n ter nationa l
Dev el opm en t

Andrew Harmer and Jonathan Kennedy

In this chapter we explore the relationship between international development and

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

widely argued that development is motivated by flawed reasoning or economic and

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

Immanent or Unintentional
Development

For most of human history the majority of people have lived close to subsistence level.
Income levels fluctuated as a result of wars, famines, and pestilence, but over the longue
 Global Health and International Development   219

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

The Great Transformation and the Great Divergence

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

not great disparities in socio-economic development between countries and regions

(Milanović 2016). In many ways, the Aztec, Inca, Arab, Chinese, and Mughal civilisa-
tions were more technologically advanced than Europe around this time (Acemoglu,
Johnson, and Robinson 2002). Even in 1750, India and China together accounted
for almost three-quarters of world industrial output (Tharoor 2017, p. 216). But coloni-
alism led to a “reversal of fortune” as Europe and its settler colonies became the
most prosperous regions in the world (Acemoglu, Johnson, and Robinson 2002).
For states at the sharp end of the colonial project, the consequences for health were
catastrophic. Latin America saw its population reduced by 95 percent between 1492
and the mid-1600s at the hands of the Spanish conquistadors (Zinn 1980). India went
from producing 23 percent of world economic output in 1600 to 3 percent by 1947 and
‘was transformed by the process of imperial rule into one of the poorest, most back-
ward, illiterate and diseased societies on earth by the time of . . . independence’ (Tharoor
2017, 216).

Globalisation and Inequality

Globalisation has been defined as the ‘broadening, deepening and speeding up of
world-wide interconnectedness in all aspects of life’ (Held et al. 1999, 2). It is not a new
phenomenon; Therborn, for example, identifies six waves of globalisation, beginning
with the diffusion of world religions and the establishment of transcontinental civilisa-
tions in the period 300–600 CE (Therborn 2000). Here we focus on its most recent, pri-
marily economic, incarnation, which began in the 1980s (see also Sparke in this volume).
Sustained economic crises in advanced economies during the preceding decade resulted
in increased dissatisfaction with the Keynesian macroeconomic policies that had been
dominant since the 1930s. The reaction against state intervention was led by what
Ha-Joon Chang (2003) has referred to as an ‘unholy alliance’ between neoclassical
economics and the Austrian-Libertarian political philosophy. This pro-market ideology
was advocated by economists such as Friedrich von Hayek and Milton Friedman and
came to be known as neo-liberalism. Its tenets are well known and strongly shape the
latest stage of globalisation: limited government, free trade, liberalisation of capital
markets, and privatisation of public enterprises and services (Stiglitz 2002). Neo-
liberalism pushed for a return to the laissez faire economic policy of which Polanyi was
so critical (Block and Somers 2014). The effects of this shift in terms of the state’s ability
to provide security for those in its charge has become a central concern for international
relations’ scholars (Held et al. 1999; Scholte 2000). In the United States and United
Kingdom these ideas were championed by Ronald Reagan and Margaret Thatcher
respectively; they were exported through the Washington Consensus, named after
institutions that were based in DC such as the International Monetary Fund (IMF),
World Bank, and US Treasury Department. Thus it is apparent that the long-term
process of social change that is often described as immanent or unintentional and is
 Global Health and International Development   221

contrasted with planned or intentional development in the literature, is in fact subject to

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

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

Globalisation and Human-Induced Climate Change

The term Capitalocene has been coined to signify that it is the capitalist system rather
than humanity per se that is responsible for environmental destruction (Moore 2017).
Capitalism requires the appropriation and exploitation of nature in order to provide
cheap food, energy, and raw materials (Moore 2017), and critical political economists
have long argued that an economic system in which the primary objective is the endless
pursuit of profit will have a catastrophic effect on the environment. As early as the
mid-nineteenth century, Karl Marx pointed to a phenomenon that he called a ‘metabolic
rift’, in which land became depleted of nutrients as it was intensely farmed to meet the
 Global Health and International Development   223

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

Planned or Intentional Development

In this section we consider whether planned or intentional development is able to

resolve intra- and international inequalities in health, and the potentially catastrophic
climate change effects created by unplanned or immanent development. The formal
practise of international development, whereby wealthy nations agree amongst them-
selves to a set of rules, goals, and conditions for assisting less wealthy nations to develop,
is a relatively recent feature of economic and political relations between states. In 1948
the United States initiated the Marshall Plan, which gave 2.5 percent of GDP to rebuild
war-ravaged Western European economies. The plan was seen as a remarkable success
and influenced the idea that similar results could be achieved if the wealthy countries
gave aid to less prosperous nations (Szirmai 2017). Aid from the Marshall Plan was
administered by the newly established Organisation for European Economic
Cooperation (OEEC), which in 1961 became the Organisation for Economic
Co-operation and Development (OECD)—an organisation comprised of OEEC
countries plus the United States and Canada, and with a global rather than European
focus. A few years earlier, the International Bank for Reconstruction and Development
(later to become incorporated into the World Bank group) and the IMF, were estab-
lished to help with reconstructing war-wrecked economies and providing financial
stability. These institutions would go on to have an enormous effect on international
development.
One of the most significant agreements made by members of the OECD was to
commit a percentage (0.7 percent) of their economic output—gross national product
(GNP)—to official development assistance (ODA). However, only a handful of countries
met this commitment: the OECD average is less than half at 0.32 percent, and the United
States, the largest international donor in absolute terms, gives just 0.19 percent (OECD
2018). The OECD has also worked since the 1960s, through its Development Assistance
Committee (DAC), to agree to the rules and norms that govern the system of inter-
national development that we see today. Between 2003 and 2011 the OECD coordin-
ated a series of high-level international meetings aimed at aid effectiveness, which
provide a framework for describing, measuring, and evaluating efforts to govern
international and, with the advent of multiple nonstate financial actors, global devel-
opment ­assistance (OECD n.d).
Initially WHO was the undisputed leader of global public health programmes.
WHO’s focus was primarily on international health—that is, stopping the transition of
infectious diseases across borders—but it also undertook a variety of interventions to
improve health in the global South (see chapter by Cueto in this volume), the most not-
able success of which was the eradication of smallpox in 1980 (Brown, Cueto, and Fee
2006). The World Health Assembly (WHA), WHO’s main decision-making body, works
on the basis of one vote per member state. As an increasing number of former colonies
joined the UN system, WHO’s policies became more radical, culminating in the Alma-
Ata declaration of 1978, which identified primary healthcare as crucial to improvement
 Global Health and International Development   225

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

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

The Goals of Contemporary International Development

The significance of health for contemporary international development efforts was
reflected in the MDGs, announced at the Millennium Summit in September 2000. All
191 UN member states committed to help achieve the eight targets by 2015 (see table 12.1).
Three targets specifically focused on health: to reduce child mortality; improve
maternal health; and combat HIV/AIDS, malaria, and other diseases—whilst the other
five referred to important determinants of health. At their conclusion in 2015, the MDGs
were described by Ban Ki-Moon as ‘the most successful anti-poverty movement in
history’ (UN 2015). Claims about their success are based on the assumptions that they
resulted in an increase in aid and that this aid was used effectively to achieve the targets
(Kenny and Sumner 2011). Regarding the first assumption, there was an increase in aid
during the period: the proportion of aid to gross national income (GNI) given by OECD

Table 12.1 UN Millennium Development Goals, 2000–2015

The eight Millennium Development Goals are

1. to eradicate extreme poverty and hunger;
2. to achieve universal primary education;
3. to promote gender equality and empower women;
4. to reduce child mortality;
5. to improve maternal health;
6. to combat HIV/AIDS, malaria, and other diseases;
7. to ensure environmental sustainability; and
8. to develop a global partnership for development.

Source: http://www.who.int/topics/millennium_development_goals/about/en/.
 Global Health and International Development   227

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

Table 12.2 UN Sustainable Development Goals, 2015–2030

1. End poverty in all its forms everywhere.

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

Source: http://www.un.org/sustainabledevelopment/sustainable-development-goals/

(Fukuda-Parr and Hulme 2009). Nevertheless, the SDG terms of engagement were decided
in advance (without wide public engagement), whilst polls encouraged participants to
prioritise those preselected development issues. More serious criticisms of the SDGs
refer to their internal contradictions and the fact that the goals do not address the
source of the problems that they aim to resolve—that is, the global economic system
that has created massive inequalities and potentially catastrophic climate change
(Hickel 2015). The SDGs are informed by Ban Ki-moon’s assertion that ‘there can be no
Plan B, because there is no Planet B’ (UN 2013). They focus on ‘the challenges of ensur-
ing more equitable development and environmental sustainability, especially the key
goal of curbing the dangers of human-induced climate change’ (Sachs 2015).
Specifically, the SDGs endorse the aim of keeping global temperature change to below 2
degrees Celsius and advocate ‘sustainable patterns of production and consumption’.
Nevertheless, they continue to endorse the system of growth-focused economics that
commodifies the environment and created climate change. For example, SDG 8 is
focused on economic growth and calls for annual GDP growth of at least 7 percent in
low-income countries (LICs).
Moreover, SDGs promote growth as the main solution to poverty reduction, but the
evidence suggests that this assumption is highly problematic. The poorest 30 percent of
 Global Health and International Development   229

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

Conclusion

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

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

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

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 chapter 13

The Politics
of Gen der a n d
Gl oba l H e a lth

Sarah Hawkes and Kent Buse

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

between sex and gender to differentiate between physical and psychological characteristics.
According to Money, gender, experienced privately, is ‘gender identity’—an individual’s
self-perceived and self-identified sense of being male or female—and expressed publicly
through ‘gender roles’ (Money 1957; Money 1973). Money’s ideas took decades to be
accepted in many parts of the health sector, but in the realm of medical research the use
of ‘gender’ now outstrips ‘sex’ in several areas of academic publishing (Haig 2004).
In this chapter we ascribe firmly to the notion that gender, embodied through distri-
butions of power and the relational nature of social interactions between people, is a
social construct (Connell 2012) that bears a significant effect on the health and well-
being of all people (Hawkes and Buse 2013). Gender, as a social construct, encompasses
both patterns of social organisation as well as ascribed roles and positions in society that
people may occupy on the basis of having a particular gender identity. Gender, as
described by Lorber (1994), is a ‘major building block in the social structures built upon
unequal statuses’, but it also describes a ‘process [that] creates the social differences that
define “woman” and “man”’. We use the UN Women (n.d.) definition of gender as refer-
ring to ‘the roles, behaviours, activities, and attributes that a given society at a given time
considers appropriate for men and women’. This definition goes on to recognise that
‘[t]hese attributes, opportunities and relationships are socially constructed and are
learned through socialization processes. They are context- and time-specific and
changeable. Gender determines what is expected, allowed and valued in a woman or a
man in a given context’ (UN Women n.d.).
Gender is embedded in unequal power relations—relationships that have historically
emphasised women’s lower social position and status. Gender equality is recognised as a
human right and has been at the core of global action and attention since at least 1946,
the year that the United Nations Economic and Social Council (ECOSOC) established
the Commission on the Status of Women (CSW). One aim of CSW was given as ‘pre-
paring recommendations and reports to the ESOCOC to promote women’s rights in
political, economic, social and educational fields’ (Sustainable Development Knowledge
Platform n.d.). Gender inequality, aside from being an abuse of human rights, has direct
and measurable effects on many social and economic outcomes, including health and
well-being. The 2008 the World Health Organization (WHO) Commission on the
Social Determinants of Health, for example, gave a clear description of the relationship
between women’s unequal position in many societies and their (lack of an) ability to
realise their rights to healthy lives (Marmot et al. 2008).
However, gender is not synonymous with ‘women’ or ‘girls’, and the gendered roles
that men occupy in most societies tend to also be associated with increased risks to their
health and well-being—mediated, for example, through gendered norms of risk-taking
behaviours (use of tobacco and alcohol). Evidence of the lower life expectancies and
poorer health outcomes for men (compared to women) has accrued for centuries; in
both England and Wales, and Sweden, men’s lower life expectancies have been systemat-
ically recorded since at least the nineteenth century (e.g., see Villegas et al. 2014 for
England Statistics Sweden 2010). Analysis of birth cohort data from thirteen economic-
ally developed countries (in Europe and North America) found an increase in adverse
male to female mortality ratios (particularly in the age group 50–70 years) since 1880.
 Politics of Gender and Global Health   239

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

Gender and Health:

A Conceptual Framework

Gender is distinct from but interacts with biological sex. Biological sex (ascribed at
birth based on the presence of male or female genitalia, occasionally resulting in a cat-
egory of ‘intersex’ when genitalia are ambiguous) has a significant influence on health
240   Sarah Hawkes and Kent Buse

outcomes and contributes to differences in morbidity, mortality, and life expectancy.

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

Gender Intersects With Other Social Determinants

of Health
Gender interacts with other social determinants of health to both reproduce inequal-
ities and promote privilege and opportunity. Crenshaw (1989) describes the interaction

Framework for
understanding and Gender equality
addressing role of and health equity
gender on health
and wellbeing

Gender intersects with Gendered institutions

other health determinants Social, Institutions Gender is embedded in institutions.
Gender is embodied Gendered policies and practices
differently through its
economic and systems
influence peoples’ experienses of
interaction with other social and organisations and systems (health,
determinants of inequality and commercial legal, political, economic, social
vulnerability, e.g. poverty, determinants welfare, etc).
occupation, education,
geography and participation. GENDER
Gender inequality and
Gender and health behaviours
discrimination can have direct
Gender is enacted through
negative effects on health and
behaviours. Gender norms,
wellbeing.
roles and expectations influence
Behaviours behavioural patterns of risk,
vulnerability and protective
behaviours.

Figure 13.1 Conceptual framework illustrating the relationship between gender and health
and well-being.
 Politics of Gender and Global Health   241

of multidimensional axes of discrimination (predominantly race and gender) as

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

Gender and Health Behaviours

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

with gender norms—and both behaviours drive a significant proportion of the health
gaps seen between men and women in many countries (Trovato and Lalu 1996; Pampel
2002; Bobak 2003; Pampel 2005; Janssen and Poppel 2015). For example, Beltrán-Sánchez
(2015) and colleagues, reporting from their analysis of cohort data sets in high-income
countries, found that the rate of mortality decline in the nineteenth and twentieth
centuries was 70 percent faster for women than men. As much as 30 percent of the excess
male mortality was calculated as being attributable to smoking tobacco, with its conse-
quent impact on risk for heart disease, stroke, and cancer.
For Courtenay (2000) and Wilsnack, Wilsnack, and Obot (2005), both tobacco and
alcohol are intimately tied up with gender norms that equate risk-taking behaviours
with positive aspects of masculinity—a norm that is perpetuated and exploited through
the actions of commercial companies that seek to use gender as a device for market seg-
mentation and success (Hawkes et al. 2018). Gendered expectations of occupation drive
differences in risk exposure in a third major area: road traffic accidents. It is estimated
that three-quarters of the 1.2 million deaths per year on the road are of men (frequently
young men) (Sengoelge et al. 2018), in part due to higher rates of exposure, as men are
more likely to be drivers, including in transport-related occupations, and possibly due
to gender-related attitudes towards driving (Bergdahl 2007) and speed.
However, gender, as previously noted, is not static and is subject to manipulation and
change. In the United Kingdom, for example, age cohort studies on populations born in
the 1930s, 1950s, and 1970s found different relationships between masculinity/femininity
and smoking prevalence in men and women from each of the cohorts, reflecting changing
gender roles across wider society (Hunt et al. 2004). Meta-analysis of alcohol-associated
harms analysed across sixty-eight studies found a significant reduction in the differ-
ences in patterns of alcohol consumption, problematic alcohol use, and health harms
due to alcohol between men and women born at the beginning of the twentieth century
compared to those born in the closing decades of the century (the gap decreased from
2:1 to 1.1:1 (male:female) for alcohol consumption, 3:1 to 1.2:1 for problematic alcohol use,
and 4:1 to 1.3:1 for health harms) (Slade et al. 2016).
This so-called gender roles modernisation hypothesis (Waldron 1997) has been used
to explain the shift to previously male-dominated behaviours when girls and women
gain autonomy (including financial autonomy) and agency. Tobacco and alcohol com-
panies have exploited this gender norm shift for many years—tobacco companies called
cigarettes marketed at women ‘torches of freedom’ as far back as the 1920s (Amos and
Haglund 2000)—and in public perception tobacco has been closely associated with
fashion, body image (slim women), and emancipation. Tobacco companies (and
increasingly, alcohol companies) looking for new markets are currently ‘capitalising on
social and economic change’ in both Africa and Asia to market cigarettes to young
women (Gilmore et al. 2015). Such tactics appear to have worked in recent decades
across Europe. Studies of smoking and alcohol use amongst girls and boys aged 15–16
years across thirty-five European countries found that the gender gap in reported
tobacco smoking rates amongst adolescent boys and girls disappeared between 1995 and
2007 (Hibbell et al. 2009), and both sexes reported similar rates of drunkenness in the
 Politics of Gender and Global Health   243

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

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

Gendered Institutions
Health (and other) systems are gendered in terms of who receives quality care (and for
what conditions), in terms of who is providing the care, and in terms of the focus of
health research. The structure of health systems in terms of ‘insurance systems, fees, the
range of services offered, patient healthcare incentives, and work structures and regula-
tions’ matters for gender equality, gender equity, and health equity (Ewig 2016). Gender
is embedded in the politics of health systems through decisions about financing
(including through processes of commercialisation and privatisation) (Mackintosh and
Koivusalo, 2005), priority-setting (decisions to focus on or exclude conditions, diseases,
and illness burdens that bear differential impacts across society), service delivery (the
gendered nature of services that are inaccessible on account of working hours or geo-
graphical location), and the quality of care delivered.
As noted previously, when health systems require payment at the point of care or are
reliant upon insurance schemes, women tend to have reduced access to services. Evidence
from India, Nigeria, Tanzania, and Colombia finds that women persistently reduce their
healthcare-seeking patterns as they have less access to financial resources, with the great-
est impact being suffered by women in poorer and female-headed households, women in
rural areas, and women with additional care-seeking responsibilities (for children or the
elderly). Furthermore, such women, when they do seek healthcare, have disproportion-
ately higher levels of out-of-pocket and catastrophic health expenditures (Brinda et
al. 2014; Onah and Govender 2014; Amaya-Lara 2016; Saikia, Moradhvaj, and Bora 2016).
 Politics of Gender and Global Health   245

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

The Gendered Health Workforce

Globally, it is estimated that over 70 percent of the health workforce is female, but
70 percent of the leadership (and 80 percent of board chairs) is male (Global Health
50/50 2018, 2019). A recent review by the WHO Global Health Workforce Network’s
Gender Equity Hub (2019) highlighted four areas contributing to gender inequity and
gender inequality in the global health workforce: occupational segregation (e.g., gender
norms mitigating against men becoming nurses), (dis)respectful workplaces (bias, dis-
crimination, and harassment common in the health system, and women less likely to
belong to trade unions), inequalities in power (women less likely to be in positions
of leadership), and inequalities in pay (reinforced by women occupying lower status
positions). Additionally, women, compared to men, in the health and social care sectors
(Newman 2014) are more likely to be engaged in unpaid labour (e.g., as community
health workers Kasteng et al. 2016), have lower access to training and professional devel-
opment (Churnrurtai et al. 2007), and report a generally lower quality of life (Kheiraoui
et al. 2012). A review of 198 organisations active in and with an interest in global health
found that whilst 70 percent of organisations had a public commitment to gender equal-
ity in the workforce, less than half had any policies, strategies, or targets to achieve such
equality (Global Health 50/50, 2019). The report also found that those workplace policies
that underpin both gender equality and diverse, inclusive, and respectful workplaces
were either not publicly available (e.g., only one-third of organisations have their sexual
harassment policies online) or did not meet global norms (fewer than one-third of
policies evaluated met best practise standards for a comprehensive sexual harassment
policy). In short, whilst gender equality may be an aspirational commitment for many
organisations active in the global health sector, the reality is that most of the same organ-
isations are operating without the necessary policies and practises to support a more
gender-equal workforce in a non-discriminatory and respectful working environment.
In summary, gender, experienced through unequal expectations, opportunities, and
responsibilities, impacts how long each of us can expect to live and our risks of ill health.
Gendered actions drive not only our exposure to health-reducing products, environments,
and circumstances, but impacts on whether or not we are likely to seek care or health
services. Moreover, gender determines who is likely to be running the health system
(men), who will provide us with ongoing care in hospital or at home (women), and how
much or whether or not people get paid for providing such care.
Despite this strong and compelling body of evidence highlighting the relationship
between gender and health and gender and career progression, reviews of organisations
that have an influence or interest in global health, find that they are predominantly ‘gen-
der blind’—that is, they fail to take gender into account in their policies, programmes,
and services (Amos et al. 2012; Hawkes and Buse 2013; Hawkes et al. 2017; Global Health
50/50, 2018). In the next section we explore in more detail the politics of gender blindness
through a review of the history of gender as a concept in global health and an explor-
ation of the roles that power and patriarchy play in determining agendas, discourse, and
responsiveness.
 Politics of Gender and Global Health   247

Gender and Global Health:

Reviewing Organisational Responses

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

of health problems often associated with their work and with changing lifestyles
or stress—such as accidents, lung cancer, alcoholism, and cardiovascular diseases.
However, women’s changing lifestyles may soon place them at equal risk for stress- and
lifestyle-related problems’. Nonetheless, the report stated that ‘[w]omen’s special health
needs are primarily related to their reproductive role’.
The first inclusion of ‘gender’ as an issue in the global health arena came in 1993 when
the Tropical Diseases Research (TDR) programme of WHO published ‘Gender and
Tropical Disease: Research to Lift Women’s Burden’ (WHO 1993); the following year
‘gender’ entered the health and development lexicon more widely when the International
Conference on Population and Development (ICPD) noted, ‘Advancing gender equality
and equity and the empowerment of women, and the elimination of all kinds of violence
against women, and ensuring women’s ability to control their own fertility, are corner-
stones of population and development-related programmes’ (ICPD PoA, 1994).
From the earliest days a discourse around gender and health arose that conflated
gender with women’s health, and in particular their reproductive health. This conflation
has continued through both the Millennium Development Goals (MDG 3, Promote
gender equality and empower women, and MDG 5, Improve maternal health) and into
the 2015 sustainable development goals (SDG 5, Achieve gender equality and empower
all women and girls, and SDG 3, Ensure healthy lives and promote well-being for all at
all ages, with its first target being a reduction in the maternal mortality ratio).
Over the past few decades there has been no dearth of policies, guidelines, strategies,
and tools developed by the multilateral system, development partners, and national
governments to make health systems more gender responsive. Frequently this has been
undertaken through a lens of gender mainstreaming—a strategy aiming to institutionalise
gender equality within systems, including health systems. True and Mintrom (2001) argue
that transnational networks, predominantly of women’s non-governmental organisations
(NGOs) in collaboration with agencies of the United Nations, have played a significant
role in the diffusion of the ideas (and policies) of gender mainstreaming globally.
Possibly as a result of the actors involved in the push for gender equality (i.e., the
feminist advocacy and activist movements, which took global shape in the 1970s and
1980s; Jaggar 2014), the focus of much of gender mainstreaming, including in global
health, is on improving health outcomes for women and girls (Smith et al. 2016; Hawkes
et al. 2017). Whilst this is understandable in terms of the inequalities of patriarchy, there
are those who are concerned that the particular focus of much medical attention is
driven by ‘biological reductionism’. This results in women being seen in health policies,
programmes, and research as people ‘whose “health” (and that of their children) is
determined by their ability to become pregnant, give birth, and adequately mother their
offspring’ (Inhorn and Whittle 2001),
Whilst the underlying principles of universality of healthcare are enshrined in human
rights principles (and law), the experience of the past several decades suggests that
­global health organisations selectively focus on segmented population groups rather
than the entire population (Seeley and Allison 2005). In the main, and as shown through
the stated areas of concern for 198 organisations active in global health (Global Health
 Politics of Gender and Global Health   249

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

The Gender Agenda of

Global Health: Current Responses

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

As noted, our review of 198 OGHs involved in norm-setting and funding at both global
and national levels found that two-thirds of the organisations gave no definition of gen-
der, and if they did define what they meant by gender, in over 90 percent of cases this did
not include recognition of non-binary identities (Global Health 50/50, 2019). The lack of
a clear definition and understanding of gender in many OGHs means that they have
generally been slow to respond either to the changing nature of women’s risk-taking in
many parts of the world or to evidence of men’s disproportionate risks for some of the
major global health problems (non-communicable diseases, violence and injury, etc.).
Despite ‘gender mainstreaming’, the approach to gender, particularly amongst the devel-
opment-based organisations, has been characterised as ‘simplification, sloganising and
lowest common denominator consensus’ (Cornwall et al. 2007).
In their review of gender in the policies and practises of international development,
Cornwall et al. (2007) challenge the frequent portrayal of women and girls as ‘both
heroines and victims: heroic in their capacities for struggle, in the stead-fastness with
which they carry the burdens of gender disadvantage and in their exercise of autonomy;
victims as those with curtailed choices, a triple work burden and on the receiving end of
male oppression and violence’. This oversimplification, they note, might ‘have the power
to move’ but is ‘very far from the complexity of women’s and men’s lives’. The ‘vulnerable
victim’ nature of much global health discourse around women and health serves to over-
look the evidence of a number of fundamental relationships between gender norms and
health outcomes that are currently being poorly addressed by the global health commu-
nity. In this chapter we have shown, for example, that not only do boys and men suffer
poor health outcomes across all age ranges, but they frequently do not access public sec-
tor (or development partner–funded) health (treatment or prevention) services.
Furthermore, men’s rates of risk exposure to major drivers of morbidity and mortality
frequently exceed those of their female peers. As a result, men’s life expectancies are cur-
tailed relative to women’s in every country in the world. Cautioning against framing
these issues either with men as a ‘public health problem’ or ‘men as victims of male roles’,
Smith et al. (2016) propose that instead public health practitioners and scholars should
focus on the social, economic, and political contexts that shape men’s experiences of
their own health trajectories. In other words, we should frame men’s experiences of
health, well-being, and illness in the realms of gender as a social determinant of outcomes
and address these determinants rather than focus solely on attempting to change indi-
vidual men themselves.
Alongside this, the predominant focus on women as ‘reproducers’ (Inhorn and
Whittle 2001), with the associated public policy focus on pregnancy, childbirth, and the
survival of young children, has resulted in the health concerns of the majority of women
being overlooked; programmes focusing on women’s risks from the major killers (dia-
betes, cancer, heart disease, and lung disease) are notable by their absence from much of
the global health discourse. Moreover, the changing nature of gender norms in much
of the world might have been seized upon by the commercial sector keen to see sales of
tobacco, alcohol, and fast food increase amongst young women (the so-far ‘untapped
market’), but the global health community has been slower to see young women’s
 Politics of Gender and Global Health   251

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

Gender and Health: The Absence

of an Effective Response

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

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

Conclusion

In this chapter we have highlighted the relative ‘gender-blindness’ of many organisations

active in global health and have contrasted that with the body of empirical evidence that
highlights the importance of gender both as a determinant of outcomes of health and
well-being and as an indicator of career progression within the health sector. Whilst gen-
der rarely acts alone (but instead intersects with other social stratifiers of powerlessness
 Politics of Gender and Global Health   253

and disadvantage), it is nonetheless one of the most important global determinants of

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

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

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

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 pa rt I I I

GL OBA L H E A LT H
G OV E R NA NC E
 chapter 14

Gl oba l H e a lth
G ov er na nce

Colin M c Innes

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

imperatives of neo-liberal market capitalism privileging profit over health needs (Fidler
2015; Gostin and Friedman 2015; Gill and Benatar 2016b; Kamradt-Scott 2016).
The system of international cooperation for health is not new. International health
regulations date back centuries, and the process of standardising them began with the
first of fourteen International Sanitary Conferences (Youde 2012, 14–17). But since the
establishment of WHO in 1948 there has been a proliferation of governance activities,
many of which originated with that organisation. These range from declarations, to best
practice guides, to conventions, to norms and moral codes. This proliferation of ‘soft
laws’ in effect created a governance regime for global health. The regulations and other
governance mechanisms, however, were largely of either a technical nature (e.g., vaccine
delivery, disease notification, marketing of health-related products) or normative
(e.g., 1978 Declaration of Alma Ata on Primary Health Care), rather than legally binding
instruments. The 2014–2016 Ebola outbreak, however, is illustrative of the contemporary
significance attached to GHG: the outbreak of a disease that had previously killed
relatively small numbers , but which became a crisis in the fall of 2014 and which was
subsequently estimated as potentially reaching 1.4 million cases in just two countries
(CDC 2014), was blamed in no small part on failures in GHG. The outbreak also demon-
strated how GHG—or rather, its failings—could become headline news and galvanise
the international community into response.
There is no small irony here, because what we have seen since around the turn of the
millennium has been a growth in governance mechanisms and agencies involved in
GHG. In particular, the study and practice of GHG has been transformed in two ways.
First, the development of a new dominant discourse of ‘global health’ required a new
way of thinking about governing health; after all, if health issues were the product of
­global processes, then it was a straightforward move to argue that health governance
had to be global. This in turn had major political consequences in implying a shift in
authority and power from national agencies to global institutions, as seen in debates
over disease surveillance and the introduction of new global bodies for this purpose
such as GOARN (the Global Outbreak Alert and Response Network), discussed later in
this chapter. Second, the emergence of this new discourse coincided with, and on occa-
sion led to, transformations in the ‘architecture’ of GHG—although GHG’s haphazard,
unplanned evolution means that this architecture appears to be less the elegant func-
tional simplicity of a neoclassical design, or even Gaudi’s organic (if somewhat fantastical)
design for Sagrada Familia, and more Mervyn Peake’s bewilderingly complex and con-
fusing Castle Gormenghast. This second transformation reflected both the growing sig-
nificance of GHG and expectations that it could—indeed, should—lead to better health
outcomes. But if the first transformation implied a shift in authority and power to the
global, the second also implied a potential diffusion of authority and power at the global
level, as the number of agencies proliferated, often with overlapping or competing man-
dates. This chapter therefore examines these two potentially competing transformations
before discussing some of their political consequences for GHG, especially concerning
the changed distribution of power (material and normative) and where authority is
vested in global health.
 Global Health Governance   267

The Transformed Discourse:

From International to Global Health

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

the discursive shift had been fully realised, such that in 2008 the United Kingdom was
able to produce a cross-departmental policy statement entitled Health is Global, arguing
that a purely national perspective on health policy was no longer adequate, given that
health was now subject to global forces (Department of Health 2008). The reason for
this shift was commonly ascribed to the material ‘fact’ of globalisation. In particular the
potential for communicable diseases to spread more rapidly because of the increased
speed and intensity of cross-border interactions was used as evidence for globalisation
affecting health (see, e.g., Lee 2003). A much-cited example was the 2002–2003 severe
acute respiratory syndrome (SARS) epidemic, which quickly spread across continents
to cities as geographically distant as Hong Kong and Toronto. But SARS also demon-
strated a more positive side of globalisation in the ability of the international scientific
community to harness its collective talents to address the disease (Fidler 2004b;
Kamradt-Scott 2015). WHO Director-General Gro Harlem Brundtland similarly located
the impact of globalisation on the spread of disease, arguing that ‘[today] there are no
health sanctuaries’; rather, humanity is ‘a single community within a common microbial
sea’ (Brundtland 1999). But the impact of globalisation was also evident in other health
issues, from the practices of large multinational food and drink companies (including
‘Big Tobacco’) popularising potentially harmful foodstuffs, to the global marketplace for
pharmaceutical products, to the widespread use of antibiotics (not least in farming)
leading to a global risk of antimicrobial resistance, to the relative ease with which health
professionals could move across borders, to aid and development policies applying
common principles across culturally diverse groups.
Less frequently remarked upon, but nevertheless important for the politics of global
health in that it affected where power and authority lay, was that globalisation was
reconceptualising communities. In particular, commentators suggested that communi-
ties may no longer be bounded by national borders, but might be global in nature.
Echoing Johan Galtung’s analysis from the 1980s, Gill and Benatar (2016a) suggested
that what distinguishes health outcomes in a global community is not so much where
you are but which social group you belong to (see also Schrecker in this volume). Thus
the poor in the United States have more in common with the poor elsewhere in terms of
health than they do with the rich in the United States. Others noted the growing emer-
gence of a global civil society; that is, social movements with transnational perspectives
and interests, usually seen as progressive forces or as key social mechanisms for giving
voice to an individual’s political interests in a globalised polity (see, e.g., Lipschutz 1992;
Falk 1995). In health terms, perhaps the most marked example of this was the emergence
of transnational groupings lobbying for the rights of people living with HIV and AIDS
(McCoy and Hilson 2009; Youde 2012, 99–114). The implication of this change in the
nature of community is a change in the nature of the polity; political actors are no longer
located within or by reference to nation-states, but rather by economic or social class or
interests on a transnational or even planetary scale.
As Jonathan Joseph has argued, however, globalisation can be seen not as a material
fact but as a way of thinking about and explaining the world, which in turn allows it to
 Global Health Governance   269

be presented as an unarguable fact to which there is no ‘common sense’ alternative

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

The Transformed Architecture

of Global Health Governance

If the narrative of global health changed expectations about governance and raised the
potential for a shift in where power and authority were located, then the emergence of
new global actors and networks has also changed not only the structure but also the
expectations of GHG and where power and authority lie. These new bodies have gener-
ated a sense of opportunity: health can be improved through new methods, greater
­political attention, and/or increased capacity. But this opportunity has in turn been
limited, both by the very proliferation of actors (creating a diffusion of authority) and by
the often anarchic structure in which these actors operate. Some of these new actors arose
directly because of the perceived need for better GHG—for example, organisations such
as GOARN, which ‘pools human and technical resources for rapid identification, con-
firmation and response to [communicable disease] outbreaks of international import-
ance’ (WHO, n.d.-a). Established in 2000 by WHO and partners, GOARN clearly
reflected a sense that globalisation had changed the risk of communicable diseases
spreading, requiring an improved, global capacity for surveillance and technical response
(such as the identification of new viruses and development of pharmaceutical responses).
Others are linked to the wider process of globalisation. For example, better global com-
munications allowed the emergence of transnational networks such as the International
AIDS Society, with members in over 180 countries. Yet others arose out of concerns at
best tangentially related to globalisation or the need for better global gov­ern­ance. For
example, the emergence of the Bill and Melinda Gates Foundation appears to have been
prompted by humanitarian concerns. With an annual budget of US$1B (in contrast to
WHO’s biennial budget of US$4B), the Gates Foundation has emerged as one of the most
significant actors in global health in the new millennium, and whilst its motivations are
rarely questioned, its lack of transparency and accountability, coupled with its ability to
shape aid and policy agendas, have led to some concerns (see Youde in this volume). In
contrast, state-led initiatives such as PEPFAR (the President’s Emergency Plan for AIDS
Relief, launched by President George W. Bush) or the Global Fund to Fight AIDS,
Tuberculosis and Malaria (hereafter Global Fund), although more transparent and
accountable, nevertheless had more complex motivations linked both to humanitarian-
ism and to the global effects of poor health (see, e.g., Dietrich 2007; Harman 2010).
Five broad developments can be identified in this transformed landscape. First, and
most common, is the increase in the number of actors and initiatives involved in global
health, creating a complex and, for many, confusing institutional landscape. In 2011, for
example, the Director-General of WHO, Margaret Chan, commented that there had
been ‘truly stunning increases in the number of actors, agencies, and initiatives funding
or implementing programmes for health development. The landscape of public health is
crowded. Activities in some areas, in some countries, are frankly chaotic’ (Chan 2011).
The increase led to accusations of policy incoherence, with gaps, overlaps, and even
 Global Health Governance   271

competing and counterproductive agendas. Whilst increased resources for health

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

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

The Politics of Global

Health Governance

These developments in both the narrative of health—that ‘health is global’—and the

transformed architecture of GHG have contributed to the increased profile of global
health issues on international agendas—including those of the G7 (and previously G8),
the G20, and UN—as well as those of individual states, most notably the massive US
commitment to AIDS relief with PEPFAR. This has occurred for a number of reasons,
including the increase in shared risk as a result of globalisation; the threat to national
and human security; the macroeconomic consequences of health crises in a globalised
economy; the new humanitarian agenda exemplified by the UN’s ‘Responsibility to
Protect’ agenda (UN n.d.; Thakur and Weiss 2009); and the actions of powerful indi-
viduals promoting global health issues, from politicians such as WHO Director-
General Gro Harlem Brundtland and former US President Barack Obama to celebrities
 Global Health Governance   273

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

amongst these would be a hierarchical power relationship, whereby GHG is informed

by wider trends and policies in global governance and in turn informs issue-specific
governance. Through this nested relationship, policy coherence and consistency would
be facilitated. An example of this might be recent policy initiatives on AMR. Within an
overall governance framework, the highlight of which was a 2016 UN General Assembly
High Level Meeting (WHO 2016), the three key governance actors in world health, food
and agriculture, and animal health (WHO, FAO, and OIE, respectively) produced a
tripartite collaboration to address this issue (WHO n.d.-b). The picture that emerges
more generally from studies on how multilevel health governance operates, however, is
less satisfactory (e.g., McInnes et al. 2014). Indeed, rather than a nested hierarchical rela-
tionship, multilevel governance resembles more a ‘bumper car’ track, on which different
governance regimes as often collide with each other as work coherently together. An
example of regimes bumping into each other on health-related issues is that of migrants:
security regimes may frame the issue in terms of the benefits of limiting or even halting
the flow of migrants into a country and recommend policies that detect and deport
illegal immigrants; public health regimes may recommend less stringent measures to
ensure access to migrants who may be vectors for the spread of disease and, if undetected
because of fear of deportation, may pose a health risk to the wider community; and
regimes focusing on rights may argue that host countries have responsibilities to people
in need. Because power is diffused, different governance regimes ‘bump into’ each other
as they pursue their own sectoral interests, whether it is one health issue colliding with
another or health bumping into other sectors.
The second consequence concerns funding, or the ‘power of the purse’. Even critics of
WHO recognise the constraints placed on this key governance body in global health,
not only by its lack of funding (WHO’s annual budget is comparable to that of a large city
hospital in a high-income country), but also by the manner in which three-quarters of
this budget is earmarked for purposes specified by donors and therefore not to be used
at the discretion of the Organisation (Stocking 2015). However, the picture is more com-
plex than a combination of underfunding and hypothecation limiting the power of
WHO as an actor. The decade beginning in 2000 saw unprecedented levels of funding
for global health initiatives—from multilateral public-private partnerships such as the
GAVI Alliance and the Global Fund, to national programmes such as PEPFAR, to char-
itable donations, most notably Warren Buffet’s estimated US$30 billion donation to the
Gates Foundation. Even following the 2008 financial crash, funding for global health
remained relatively high (Murray and Dieleman n.d.). This is not to suggest that funding
has been sufficient to meet global health needs because of this increase, but rather that a
‘market’ of funding has emerged. The power of the purse to set agendas has accordingly
become more complex because of the multiple funding mechanisms and donors
involved. This includes not simply the identification of which diseases need funding, but
how to address issues (e.g., the tension between ‘vertical’ funding for specific diseases
versus more generic health system strengthening) and funding modalities, which create
power relationships between donors and recipients of aid (although recent work has
suggested that power is not monopolised by donors, and civil society groups in receipt
of aid may also exercise power over donors; see, e.g., Anderson and Patterson 2017).
 Global Health Governance   275

A third consequence is that raised expectations for GHG have created challenges
for the nature of political authority. In particular, the form of authority vested in
­gov­ern­ance bodies (especially WHO) may no longer be sufficient to meet the trans-
formed expectations provided by the narrative of global health. But to grant these
bodies different forms of authority may lead to a change in power relations between
them and states. Avant, Finnemore, and Sell (2008) identify four different types of
authority:

• delegated authority, in which states have ‘loaned’ to a governing actor the ability to
act in certain areas;
• expert (or expertise-based) authority, based on the actor’s technical expertise;
• principled (or principle-based) authority, based on acceptance of and adherence
to a set of values; and
• capacity-based authority, based on the actor’s competence and ability to undertake
effective action.

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

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

Conclusion

In conclusion, GHG is evolving as a result of two transformations. The first concerns a

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

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

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 chapter 15

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

Ted Schrecker

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

states and their decision-making processes. Federalism and devolution introduce

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

Health within Borders

Almost all states provide and finance some healthcare, although in many low-income
jurisdictions budgets are comparatively minuscule. It is a bitter irony that the lower the
per capita income in a country, the larger the proportion of healthcare that is financed
out-of-pocket, leading to a pernicious poverty trap. However, there is no direct correl-
ation among per capita income, public spending on health, and health outcomes. For
example, Drèze and Sen point out that India ‘is falling behind every other South Asian
country (with the exception of Pakistan) in terms of many social indicators, even as it is
doing spectacularly better than these countries’ in income growth (2013, 50–54).
Notably, on indicators such as child mortality, access to improved sanitation, and
immunization, India’s performance lags behind that of substantially poorer Bangladesh,
such that Drèze and Sen characterize the country as facing a healthcare crisis (143–181).
Shortly after their book appeared, a newly elected national government announced a
 THE State and Global Health   283

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

Especially interesting is the work of Kelsall, Hart, and Laws (2016) on the conditions
under which ‘political settlements’ are more or less likely to advance progress toward
UHC. Although multiple definitions of political settlements exist, it suffices here to
quote two: ‘the forging of a common understanding, usually between political elites,
that their best interests or beliefs are served through acquiescence to a framework for
administering political power’ (UK Department for International Development, quoted
in Di John and Putzel 2009, 4) and, in a formulation that recalls the analysis of North
and colleagues, ‘the set of institutional relationships through which a country
restrains violence’ (B. Levy, quoted in Kelsall et al. 2016, 7–8). This approach recognizes
the importance of renewed attention to state and nonstate elites and their interactions—
an approach that until recently had fallen out of favor in the study of national and
subnational politics. Kelsall and colleagues attempt to apply a fourfold typology of
political settlements to six low- and lower-middle-income countries, with results that
they concede are inconclusive, partly because of the unevenness in progress within
countries. Such typologies are probably less useful than the underlying insight that the
distribution of political resources within societies is fundamental to understanding
prospects for UHC; is influenced powerfully by historical considerations (and in many
circumstances also by external actors); and may involve situations in which large
portions of the population have little or no influence over the terms of the political
settlement, except when extraordinary events create volatile situations and the potential
for large-scale social change. Put more simply, any approach that treats states and
­political systems as ‘black boxes’ will contribute little to our understanding of such
issues as progress toward UHC.
Healthcare policy and financing are only part of the picture. Given what is now
known about social determinants of health (Commission on Social Determinants of
Health 2008; Kelly and Doohan 2012), it is axiomatic that health is influenced by much
more than the availability and quality of healthcare. Correspondingly, state policies in
many areas are implicated in the level and distribution of health outcomes. Of notable
importance are policies that affect levels of poverty and economic inequality (and
thereby such variables as nutrition), access to safe drinking water and sanitation, and
exposure to hazardous living and working conditions. Reflecting the complexities
referred to in the chapter’s introduction, it cannot be assumed that health will have the
same priority across policy fields. As an example of the uneven progress within coun-
tries noted by Kelsall and colleagues, Chowdhury et al. (2013) note the ‘Bangladesh
paradox’, in which more favorable health outcomes than would be expected given the
country’s poverty, and a strongly equity-oriented approach to health system design,
coexist with pervasive poverty and high prevalence (nearly 50 percent) of child malnu-
trition. The garment industry that is Bangladesh’s major export success story is becom-
ing notorious for industrial accidents reminiscent of the Triangle Shirtwaist fire a
century ago in New York City (Brooks 2007, 85; Yardley 2012), arguably reflecting a
­political context in which 10 percent of national legislators are garment factory owners
(Yardley 2013), and literally thousands of former public servants and army personnel
 THE State and Global Health   285

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

Health Beyond Borders: Global Health

Politics and Policy (In)coherence

Similar complexities characterize the relatively recent emergence of global health as an

item on the foreign policy agenda—and here the focus shifts to the HICs. Although glo-
bal health’s importance in such fora as the G7/G8 waxes and wanes, it has intermittently
been prominent on summit agendas. The G7/G8 were important in establishing the
Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria (for details on the Global
Fund see Bartsch 2007; Kapilashrami and Hanefeld 2014), and summits (with Japanese
leadership) have been important milestones in placing UHC on the development policy
agenda (Reich and Takemi 2009; Takemi and Reich 2009). In parallel with the question
asked previously about states and the health of their citizens, we should ask: Why do
states care about the health of those outside their borders? And what affects their prior-
ities? For it is clear that they do care, at least some of the time. In addition to the develop-
ments just cited, one indication is the value of development assistance for health, which
more than quadrupled in real terms between 1990 and around 2010 (Dieleman et al.
2016), and although the value stabilized after the financial crisis, the sums in question
did not decline substantially, as many had feared.
What motivates such concerns, what accounts for priorities, and what explains the
differences among states? It is axiomatic that security (of nation states in geopolitical
terms, and of people within their borders, in particular with regard to communicable
diseases) is the oldest and often dominant motivation and tends to crowd out other
motivations. As an extreme example, in December 2014 President Barack Obama called
on Congress to appropriate US$6.2 billion in emergency funding to fight the Ebola
virus, although three months later there were only four confirmed cases in the United
States. Looking further back, at the turn of the century the HIV/AIDS epidemic was
considered ‘a threat to both human and national security,’ in the words of a background
document for the first-ever UN General Assembly Special Session on a health topic
(United Nations 2001). Despite the epidemic’s devastating effects on life expectancy in
several sub-Saharan countries, the more apocalyptic predictions of effects on social and
political stability failed to materialize (Fourie 2007). Security concerns on their own no
longer provide a sufficient explanation, and Ingram has gone to some lengths to dis-
tinguish the response to AIDS as a ‘biosecurity’ issue (in Foucauldian terms) from the
institutional forms in which concerns about security associated with ‘outbreak-type
events’ (2010, 299) have been manifested. However, HIV/AIDS continues to draw a
large portion of some development assistance budgets: almost 30 percent of all develop-
ment assistance for health in 2015 (Dieleman et al. 2016).
The United States, where the epidemic was intensely politicized early on, accounts for
a large proportion of this amount; more than half of all US development assistance for
health in recent years has gone to HIV/AIDS (Dieleman, Graves, and Johnson, et al.
2015). No evidence suggests that this consistent commitment arose from security
 THE State and Global Health   287

concerns; rather, it appears to be the result of an improbable bipartisan coalition in support

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

objective through ‘TRIPS-plus’ provisions in bilateral and regional trade agreements

and seek to deter countries from using the flexibilities that are allowed under trade
agreements using unilateral mechanisms like the US Section 301 Priority Watch Lists
and the European Commission’s priority country list (Health Action International and
Médecins sans Frontières 2015; United Nations Secretary-General’s High-Level Panel
2016; Zhou 2016).
Unfortunately the literature on policy incoherence in trade and health is mainly
descriptive and does not investigate the underlying political economy. This is an important
omission because lack of policy coherence is not confined to trade policy; it extends, for
example, to the destructive consequences of the economic restructuring demanded of
LMICs by the World Bank and IMF, with the widely used phrase ‘the Washington
Consensus’ (Williamson 1990) betraying its origins. Against this background, in 2015
the UN General Assembly adopted a set of ambitious SDGs, the achievement of which
will require by one estimate annual public and private investment of US$2.5 trillion
(UNCTAD 2014), compared to current development assistance of approximately $135
billion. Expansion of health coverage is one of the targets associated with the SDGs; so,
too, are a variety of health-related outcomes in the areas of poverty reduction, food
security, and environmental exposures. If adoption of these goals is understood as more
than simple hypocrisy on the part of states that have no intention of mobilizing the
necessary resources, which cannot be ruled out, then a variety of tensions between
economic or commercial and health policy objectives will arise, of which two of the
most important are addressed here.
First, the fiscal burden of foreign debt for many LMICs was succinctly described
by an advisory body to the UN Secretary-General in 2005: ‘[D]ozens of heavily
indebted poor and middle-income countries are forced by creditor governments to
spend large parts of their limited tax receipts on debt service, undermining their
ability to finance investments in human capital and infrastructure. In a pointless and
debilitating churning of resources, the creditors provide development assistance
with one hand and then withdraw it in debt servicing with the other’ (UN Millennium
Project 2005, 35). Subsequent debt cancelation initiatives eased some elements of the
burden, but it has actually worsened in other respects: ‘Annual debt service on exter-
nal debt has risen to US$575 billion, about four times the amount that is reported as
official development assistance (ODA). The first developing country debt crisis is
therefore the crisis of opportunity costs. Each dollar that is transferred to creditors
abroad is a dollar that goes missing to finance the implementation of the SDGs at
home’ (Ellmers 2016, 7). Second, tax avoidance by transnational corporations
(TNCs) and ultra-wealthy individuals is increasingly recognized as potentially
destructive of the fiscal capacity of most states and of special importance to LMICs
that are committed to such objectives as progressing toward UHC, yet efforts at multi-
lateral cooperation are likely to encounter serious domestic resistance from several
quarters, in jurisdictions across the income spectrum. If it is too much to hope for a
health-in-all-policies orientation in foreign policy, even a ‘first, do no harm’ position
would be an improvement on current practice.
 THE State and Global Health   289

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

Reports of the Death of the

State Have Been Exaggerated

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

inter alia by a proliferation of nonstate actors—civil society organizations, private

foundations and transnational corporations among them—that routinely operate both
within and across national borders. Third, in a similar vein Robinson (2004, 85–144) in
particular argues that, in parallel with globalization and the emergence of a transnational
capitalist class (Carroll 2010; Robinson and Harris 2000; Sklair 2005; van Fossen 2012), a
nascent transnational state can be observed. It comprises a variety of economic and pol-
itical organizations and governance frameworks, including the development banks, the
WTO, forums like the G7, and the supranational administrative structures estab-
lished under trade and investment agreements. This observation is intriguing and
important even if one questions the notion of a transnational capitalist class.4
Each line of argument points to important features of global health politics and the
role of the state, but each also runs the risk of overstating a case. To take first the claim
about the transnational state, it is beyond serious dispute that agencies like the World
Bank and IMF, in their role as sources of both finance and technocratic expertise, wield
considerable influence over LMIC governments, and that their alliances with domestic
elites and political executives can circumvent many routes of domestic political account-
ability (Stichelmans 2016; and see Babb 2002 for a case study on Mexico). At the same
time, decision-making in those organizations is controlled by the governments of
member countries, primarily by a few large, rich members (on the consequences for
managing the Greek debt crisis, which has already had important health impacts, see
Thomas 2016). Apart from the important ability of institutions like the World Bank and
IMF to offer or withhold finance and to act as gatekeepers with respect to funds from
other sources, what Robinson calls the transnational state relies for its ‘hard edge’ almost
exclusively on the powers of nation states. Even the arbitration mechanisms that enforce
investor-state dispute settlement provisions of trade and investment agreements rely on
national court systems for enforcement, and the agreements themselves are between
nation states; that is the basis for their grant of legal standing to private actors. Thus,
whatever state-like characteristics the transnational state possesses, it is a different
kind of organism from the state at the national or subnational level, just as the ‘bind-
ingness’ of international law is normally quite distinct from that of domestic law in
its mechanisms of operation.
Claims about a post-Westphalian environment likewise capture important elements
of contemporary global health politics. Transnational civil society networks have
exerted substantial influence on issues such as intellectual property protection, the
pricing of medicines, and—in the broader development policy context—debt relief (the
Jubilee 2000 campaign). On global health policy and related areas of development their
research is often of higher quality than that emanating from the academic world, and
certainly more timely. Private philanthropies—the Bill and Melinda Gates Foundation,
which spends more annually on health than the core budget of WHO, in particular—
have emerged as important sources of finance for global health interventions and influ-
ences on the policy agenda (Birn 2005, 2014; McGoey 2014). Arguably the quintessential
post-Westphalian institution in global health is the H8, an informal policy forum
comprising WHO; three other UN system agencies; the Global Fund and GAVI
 THE State and Global Health   291

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

Conclusion

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

Notes
1. Recognizing the critical importance of public finance to the public’s health, the analysis
also emphasizes the importance of such matters as international cooperation to limit tax
avoidance and the consequent limitations on governments’ fiscal space.
2. I have cited a leading liberal democratic theorist rather than any one of several Marxist
formulations that are arguably more analytically rigorous (e.g., Offe 1984), in order to
demonstrate the breadth of this understanding, even though it often remains in the
background of policy analysis.
3. Thus, it was reported in 2016 that US-based TNCs held US$2.5 trillion in cash reserves
outside the United States, associated with earnings booked abroad and internal transfers to
foreign subsidiaries and affiliates, partly because of reluctance to repatriate the profits
given relatively high US corporate tax rates (Cox 2016).
4. In my view the emergence of such a class is now empirically observable beyond serious
dispute, even as its boundaries remain contestable.
5. Which is only reliably established through a state-based system of property rights. The
situation of early post-Soviet Russia shows what happens otherwise, and that legally
enforceable property rights and access to effective means of violence are under some
conditions substitutable one for the other.
 THE State and Global Health   293

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 chapter 16

Em ergi ng Pow ers

a n d Gl oba l H e a lth
G ov er na nce
The Case of BRICS Countries

Yanzhong Huang

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

position because ‘[t]heir still-transforming economies and health systems connect

them directly to the concerns of the developing world, while their growing economic
and political clout give them a place at the table with industrialized countries and a more
powerful voice in global affairs’.
This chapter discusses the profound implications arising from the growing and future
role of emerging powers in GHG. What role have BRICS countries played in shaping
GHG vis-à-vis domestic-health-related demands? To what extent has their status as
emerging powers led them to play a distinctive role and promote a separate agenda from
more established powers in GHG? How viable and sustainable is emerging powers’
engagement in GHG?
In assessing the role of China and India in GHG, Huang (2013) adopts an analytical
framework that focuses on health-related development assistance, the development of
and compliance with global health rules, and the promulgation of ideas for GHG. This
approach is built on a heuristic device first developed by the critical theorist Robert Cox
(1981), who identified the combination of three ‘categories of forces’ to constitute the
‘anatomy of influence’ or ‘framework for action’: material benefits, institutions, and
ideas. Harmer and Buse (2014), too, drew on Cox’s work in describing BRICS nations’
contribution to global health. Given the similarities of the subject matter, this chapter
adapts a similar three-force analytical framework—institutional influence, material
capabilities, and competing visions—to examine the influence of emerging powers in
GHG. An examination of BRICS countries’ vision, institutions, influence, and material
capabilities shows a distinctive and positive role they can play in GHG, especially in
terms of providing development assistance for health (DAH), developing and partici-
pating in global-health-related institutions, and presenting an alternative vision of
GHG. Their influence in engaging GHG nevertheless remains conditioned and con-
strained by their relatively small DAH size and a selective and state-centric approach to
GHG, which undermines the robustness and attractiveness of their vision of it. Future
research should pay more attention to exploring the incentives and capabilities of BRICS
countries’ GHG involvement.

Institutional Influence

Global governance encompasses ‘the totality of institutions, policies, norms, procedures

and initiatives’ through which states and nonstate actors respond to transnational
challenges (Committee for Development Policy 2014). Institutions that affect GHG
therefore can be organizational or rule-based. Over the past couple of decades BRICS
nations have become increasingly involved in the development of institutional instruments
for GHG.
 Emerging Powers and Global Health Governance   303

The Venues for Engagement

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

only Russia is a member of the G8, all the leading emerging economies participate in
the G20. Russia’s initial efforts to exercise global health leadership within the G8 was
demonstrated at the 2006 St. Petersburg Summit, during which health was chosen as
one of the top priorities.
When participating in these institutions, BRICS nations so far seem reluctant to
commit to a collective position beyond general endorsements of support. Instead, they
prefer to have the flexibility to adopt individual positions on the issues in question
(Harmer and Buse 2014). As Andrew Harmer (2014) noted: ‘there are few tangible
examples of the BRICS countries working together on health’. Occasionally BRICS
countries were united in their efforts to promote agendas of common interest (e.g., uni-
versal access to quality health technologies) (Gautier et al. 2014). Depending on the
issue, they may also form ad hoc, temporary partnerships. For example, Brazil and India
cooperated on intellectual property (IP) and universal access to medicines, while China,
India, and Russia joined together on health security and surveillance issues (Gautier et
al. 2014). Their level of involvement in WHO also varies. During WHO reform debates,
for example, Brazil was the most active among the BRICS nations, followed by India,
South Africa, China, and Russia (the least active) (Gautier et al. 2014).
Over time, BRICS countries have recognized the need to offer a more unified, distinctive
voice and perspective on global health, while enhancing cooperation among themselves.
This began in the Doha Round negotiations over Trade-Related Aspects of Intellectual
Property (TRIPS) and public health, in which India, South Africa, Brazil, and China
acted as part of a single bloc to press the United States to better accommodate the inter-
ests of developing countries in providing generic therapies for the poor. In 2009 the bloc
became institutionalized with the formation of the BASIC group, to act jointly at the
United Nations Climate Change Conference. Inter-BRICS health cooperation gained
further momentum two years later, when health ministers held their first meeting in
Beijing, committing themselves to using the platform as a ‘forum of co-ordination, co-
operation and consultation on relevant matters related to global public health’ (BRICS
Health Ministers 2011). The theme of the first meeting was ‘Global Health—Access to
Medicine.’ Since then BRICS countries’ health ministers have met annually, focusing on
advancing inter-BRICS cooperation over issues such as emerging health threats, AIDS,
tuberculosis, and non-communicable diseases (NCDs). Since 2012 the BRICS countries
have also met on an annual basis at the World Health Assembly (WHA). At the sixty-sixth
WHA, for example, they agreed to identify national institutions that could collaborate
with WHO in developing a monitoring framework to help track progress toward univer-
sal health coverage (UHC) (McKee et al. 2014).
Other institutions formed by BRICS countries may not have a direct bearing on GHG,
but they suggest emerging powers’ financial contributions to global health is shifting
from rhetoric to institutional reality. In 2013 BRICS leaders agreed to set up a new BRICS
financing instrument to complement, if not compete with, the existing efforts of multi-
lateral and regional financial institutions for global growth and development. Entering
into force in July 2015, the New Development Bank has an initial contingent reserve
arrangement of US$100 billion. The following year, China launched the Asian
Infrastructure Investment Bank (AIIB) to address needs across Asia. As a new multilateral
 Emerging Powers and Global Health Governance   305

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

The Effectiveness of
the Institutional Involvement

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

by focusing on areas WHO is unable or unwilling to address, such as pushing for more
effective WHO reform and promoting universal access to medicines.
As far as agenda setting and norm development are concerned, evidence suggests
BRICS countries have historically not shown strong interest in being issue leaders.
Scholars pointed out that BRICS countries did not officially engage in the thematic
consultation on health when setting the post-2015 sustainable development agenda
(Harmer and Buse 2014). Brazil, often considered the most active among emerging
powers in conducting health diplomacy, has not yet used its role in international institu-
tions such as the G20 and BRICS to promote health issues (Kirton, Kulik, and Bracht
2014). Leading emerging powers may host PSIs, but they often fail to use the current
window of opportunity to champion global health. For example, there was little reference
to health at the Durban BRICS Summit, indicating that South Africa’s global influence
has been limited mostly to domestic issues (Kirton, Kulik, and Bracht 2014). Similarly,
while the G20 Summit hosted by China in 2016 highlighted the country’s role as an
agenda setter in global governance, global health overall was not addressed as a priority
concern. Indeed, prior to the summit, the eighteen-page document outlining China’s
G20 plan did not mention health at all (Huang 2016b). This lack of global health leader-
ship may have something to do with the fact that BRICS countries are not particularly
well represented in the governing bodies of major global-health-related institutions. As
of June 2017, while WHO was headed by a Chinese national (who stepped down on July
1), other organizations, including UNICEF, UNAIDS, and the Global Fund to Fight
AIDS, Tuberculosis and Malaria (the Global Fund), rarely had representatives from
emerging economies either serving in executive positions or chairing (or co-chairing)
the governing bodies. That said, in some specific areas BRICS countries were able to play
a leadership role in agenda setting. For example, Brazil was instrumental in raising the
profile of the social determinants of health on the WHO reform agenda (Gautier et
al. 2014), India was successful in pushing the WHA and the UNGA (United Nations
General Assembly) to approve a resolution to develop a common action plan addressing
mental health (Dhar 2012), and Russia displayed leadership in supporting the inclusion
of NCDs on the global health agenda (Bliss 2013).
Emerging powers have also shown a willingness to work with other global health
actors in setting global health rules and norms. According to Lee, Chagas, and Novotny
(2010), Brazil showed soft-power leadership in the negotiation of the Framework
Convention on Tobacco Control (FCTC), which has been viewed as a prototypical
example of health diplomacy. Despite resistance from its significant state-owned
tobacco industry, China was considered the least vigorous opponent among the ‘big four’
(China, Japan, Germany, and the United States) during the development of the treaty. A
staunch defender of state sovereignty, China showed flexibility in revising the
International Health Regulations (IHR) so that WHO could use information from non-
state actors in decision-making. Similarly, although India was less proactive in its par-
ticipation in the IHR revision process, it has played a constructive role in the
development of other international norms, most notably the FCTC, TRIPS and public
health, and the Pandemic Influenza Preparedness Framework (Huang 2013).
 Emerging Powers and Global Health Governance   307

Equally important, BRICS countries have made important advances in implementing

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

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

Material Capabilities

Development Assistance for Health

In terms of the material capabilities BRICS countries can mobilize for global health,
their growing ability to provide DAH stands out. Although most emerging economies
have been long-standing recipients of foreign aid, they have also had a long history of
providing development assistance. Russia and Brazil started their foreign assistance
programmes—of which health was a focus—around six decades ago (Harmer, Xiao,
Missoni, and Tediosi 2013). China’s DAH is traced back to the dispatch of medical teams
to Algeria in 1963. In health-related development assistance, the preferred channel varies
from bilateral (India, China, South Africa), to trilateral (Brazil), to multilateral (Russia).
In the past decade, growing economic strength has enabled most of the emerging
economies to move away from net recipient status to net donor status. China is making
steady progress toward fully becoming a donor. In Africa the growing demand for
resources and markets, as well as its efforts to expand its influence on the continent,
intensified China’s competition with Organisation for Economic Co-operation and
Development (OECD) donors, such as Japan, driving up the level of foreign aid to the
continent (Huang 2014; Xie 2013). As early as 2007, in recognition of its role in offering
overseas development assistance, the World Bank’s International Development
Association included China as a donor. The shift to a net donor was also the result of its
decline as a recipient of foreign aid. In 2010 China received US$646 million as foreign
aid, or approximately 0.01 per cent of its gross national income (GNI) (Development
Initiatives 2012). The change is clear in China’s health sector: in 2011 the Global Fund
announced that China would no longer be eligible to apply for funding. By the end of
2012 all bilateral programmes aimed at supporting China’s health sector ceased to exist.
India and Brazil soon followed China’s in this process. Between 1967 and 2010 net offi-
cial development assistance received as a percentage of GNI in India dropped from 2.79
to 0.17 (World Bank Group 2016). A data crosscheck by Le Monde Diplomatique
Brasilthe found that Brazil offered more international assistance than it received from
countries and multilateral agencies between 2005 and 2009 (Apolinario 2016). Indeed,
official development assistance that Brazil provided doubled between 2007 and 2008
and tripled from 2009 to 2010 (Frayssinet 2011).
Due to the lack of systematic, internationally comparable data on their aid activities,
tracking flows of DAH provided by BRICS countries is not an easy job (Fan et al. 2014).
The difficulty of quantifying their DAH levels is compounded by the fact that ‘such aid is
 Emerging Powers and Global Health Governance   309

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

domestic contribution to global health improvement; in part because of its high hospital
delivery rate, China accounted for over one-quarter of the reduction in infant mortality
worldwide during 1990–2012 (Huang 2017b).
Thus, while many emerging economies have ramped up DAH, from emerging econ-
omies it remains minuscule compared to that from traditional OECD donors. About
60 per cent of US aid in Africa, for example, goes to health-related programmes alone
(Brautigam 2011). By contrast, the health component only accounts for 25 per cent of
Russia’s foreign aid and 17 per cent of Brazil’s (Harmer et al. 2013). China’s annual spend-
ing on global health is about $200 to $300 million, far less than US government funding
for global health (about $10 billion) (Valentine, Wexler, and Kates 2016). During the
Ebola outbreak in West Africa, four BRICS countries (without South Africa) combined
contributed to only 2.5 per cent of the UN’s main Ebola relief fund, compared with
45 per cent from the United States (Financial Tracking Service 2017). Also, until recently
BRICS countries have not significantly stepped up their financial commitments to global
health institutions such as the Global Fund and the GAVI Alliance (Kickbusch 2014).
In 2012 the BRICS provided only 3.1 per cent of total WHO contributions (assessed and
voluntary) (Gautier et al. 2014).
Studies suggest limited financial resources also explain why emerging economies
have targeted their DAH more selectively and strategically. As Harmer and Buse (2014, 12)
note, in terms of DAH from BRICS nations, ‘it is not the size of a country’s material
capability that ultimately matters; it is how that capacity is put to best use’. BRICS coun-
tries prefer to leverage areas in which they maintain a comparative advantage, which
involves a combination of raw materials, technical capacity, manufacturing conditions,
and new markets. Examples include Brazil promoting cooperation with Lusophone
countries (e.g., East Timor, Mozambique, Angola, and Guinea-Bissau) to strengthen
health education, technical assistance, and research; China investing in hospitals and
antimalarial clinics as part of its strong interest in infrastructure development as well as
its success in developing antimalarial drugs; and India taking advantage of its information
and communications technology to connect to hospitals and universities in Western
Africa to facilitate an information exchange of best practices through the Pan-African
e-Network. There are certainly exceptions. Russia has one of the highest ratios of health
workers per capita, but it has less interest in practicing medical internationalism (i.e.,
sending medical professionals to serve in other countries) than does China (Harmer
and Buse 2014). By contrast, China has a low ratio of health workers (Encyclopedia of the
Nations 2005), but it has sent a total of more than twenty-three thousand medical workers
to sixty-seven countries and regions. In 2015 alone China had fifty-two medical teams
stationed in fifty-one countries.
As far as motivations behind DAH are concerned, studies undertaken to date show
that foreign policy and development goals have been strong underlying forces driving the
emerging powers’ DAH agendas. In terms of regional priorities, DAH has been focused
on neighbor countries. The need to assuage the fears of its Asian neighbors has led China
to concentrate DAH in East and Southeast Asia, aside from Africa. India’s DAH is
directed primarily toward its proximate neighbors, namely Bhutan and Nepal. Anxiety
over Afghanistan’s relationship with Pakistan was a critical factor in leading India to
 Emerging Powers and Global Health Governance   311

become a major supporter of reconstruction in Afghanistan, which has received most of

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

Leading Manufacturers
of Low-Cost Medicine

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

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

Competing Visions

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

An Alternative Model of DAH?

The growing role of emerging powers appears to be leading to a reshaping of the land-
scape of global health cooperation, in part because the nature and modalities of their
foreign aid programmes are different from those of traditional donors. Positioning
themselves as ‘development partners’ rather than aid donors, they emphasize cooperation
 Emerging Powers and Global Health Governance   313

between developing countries (Acharya et al. 2014). In contrast with donor-driven

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

A State-Centric Approach to International

Health Cooperation
Another competing vision of GHG concerns the role of the state. Although BRICS
countries register a desire for an alternative model for GHG, they continue to stress
the importance of Westphalian norms of state sovereignty and noninterference, and
314   Yanzhong Huang

some also discourage the participation of nonstate actors. The IHR negotiations
­provide a useful example for examining state centrism. Prior to regional consultations
and intergovernmental working group (IGWG) negotiations, China and India declined
to gather input from local non-governmental organizations (NGOs) and even sought
to limit their role (Kamradt-Scott, Lee, and Xu 2013). At the same time, sovereignty con-
cerns led China to oppose a move to recognize Taiwan’s status at the WHA. Keenly
aware that the principle of ‘universal application’ to the IHR might be used by Taiwan to
justify formal WHO membership, China’s chief negotiator contended that ‘health is a
very important issue, but sovereignty and territorial integrity are more important’
(Sha 2004). China later softened its stance and allowed Taiwan to obtain special observer
status at the WHA, granted on an annual basis. However, Taiwan is still not permitted
to liaise with WHO other than with its headquarters in Geneva. Later, after the pro-
independence government of Tsai Ing-wen was elected and the Taiwanese government
no longer accepted the ‘One China’ principle, China withdrew its support for Taiwan’s
WHA observer status.
A state-centric approach is also evidenced in the approach to WHO reform by emer-
ging powers. As an international organization established after World War II, WHO
is a member-state-run organization in which every country has a vote in its plenary
decision-making body (i.e., the WHA). While many emerging powers favour conducting
DAH on a bilateral basis, BRICS nations in the context of reforming WHO are committed
to strengthening and legitimizing WHO through the principle of multilateralism (BRICS
Ministry of External Relations 2012). But many argue that member states, which help
shape WHO’s priorities and thus the Secretariat’s mandate, are also to blame for not
providing the Secretariat with the necessary authority and resources to push meaning-
ful reforms forward (Huang 2016a). Paradoxically, perhaps, BRICS countries favour
strengthening the power of member states rather than broadening membership to
include nonstate actors. Some BRICS countries (Brazil, India, and South Africa) might
be supportive of the involvement of nonstate actors, but they have been reluctant to
involve the corporate sector and influential private foundations in WHO decision-making
(Gautier et al. 2014). This contrasts with the position of countries in Europe and America,
which support multi-stakeholder participation in GHG.
Furthermore, in working with external actors (e.g., NGOs and intergovernmental
organizations) on domestic health projects, emerging economies are conscious of not
allowing external actors’ views to prevail. Believing in its own ability to handle domestic
health needs, for example, the Indian government has increasingly taken control over
the anti-polio campaign at home. Russia and China took a similar approach to the activities
of the Global Fund domestically. A key element of the Global Fund partnership is the
Country Coordinating Mechanism (CCM), which includes representatives from gov-
ernment, the private sector, technical partners, civil society, and patient communities.
Nevertheless, the idea of a CCM has never been internalized by the governments of
Russia and China. In 2009 Russia decided not to apply for Global Fund grants. Studies
show that the government’s refusal to fund harm reduction resulted in a surge in new
HIV/AIDS infection rates, in contrast with global trends (Bennett and Kravchenko 2014).
 Emerging Powers and Global Health Governance   315

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

Domestic Health Model

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

approaches, received widespread international recognition and was cited as an example

for other countries to follow (Kirton, Kulik, and Bracht 2014). China joined Brazil in
the UHC movement in 2009, when it kicked off a new round of healthcare reforms to
provide basic UHC to its population. By 2012 China had put in place a system of basic
medical insurance that covers almost the entire population of nearly 1.4 billion people.
Evidence suggests these efforts are paying off. China’s average life expectancy at birth
had increased from 74.8 in 2010 to 76.1 by 2015, significantly higher than the world average
of 71.4 and on a par with much of Eastern Europe.
In developing a framework for providing affordable healthcare to its people, India is
often described as practicing ‘frugal innovation’; that is, finding ‘the simplest and cheapest
way of doing something without compromising effectiveness’ (Shetty 2012).4 In putting
innovation to work, India’s business leaders and health providers have collaborated with
government actors, private hospitals, and the information technology and telecommu-
nications sectors. Some of the health-related innovations are the Aravind Eye Care
System (which earns money from rich patients and uses that to subsidize poor patients,
who receive low-cost or free care) and the LifeSpring Hospital System (a joint venture
between the Acumen Fund and Hindustan Latex to provide reproductive and pediatric
care to low-income urban mothers and their children) (Ruger and Ng 2010). In 2000
Dr Devi Shetty founded Narayana Hrudalaya (NH) in Bangalore. By embracing mass
production, he is able to make quality healthcare financially accessible to a wider range
of people. As a result of Shetty’s innovation, India is on course to become the first country
in the world to delink health from wealth.
But the experience of BRICS countries’ domestic health development is by no means
an unproblematic example that others can follow. In addition to the high risk of infectious
disease and the looming threat of NCDs, these countries are still struggling with the
challenge of finding an effective model to provide quality and affordable healthcare to
their huge populations. While India’s healthcare system is plagued by a lack of infra-
structure and inefficient workforce (Thakur et al. 2017), Brazil’s system is facing sustain-
ability problems due to misused resources, political upheaval, and a funding crisis.
Theoretically, China’s rapid economic development should create fertile ground for
innovative ideas to achieve UHC. According to some analysts, China’s development
model emphasizes a country’s own characteristics (as opposed to a one-size-fits-all
model), with willingness to innovate and experiment (Cooper Ramo 2004). However,
this philosophy, also known as the ‘Beijing Consensus’, has not led to significant innov-
ations in healthcare reform. Many of the ideas put forth by Chinese policymakers are
not novel. The widely acclaimed new cooperative medical scheme covers nearly the
entire rural population of China, but it is simply a revival of the Maoist Cooperative
Medical Schemes. Chinese healthcare reform has also fallen increasingly under the sway
of Western healthcare models. Since the beginning, debates about reform have centred
on whether to adopt a government-focused approach inspired by the British model, in
which the government provides basic healthcare for free, or a market-focused approach
influenced by the German model, which favours the use of third parties to provide
health services. In terms of the impact of ideas and visions for GHG, BRICS nations’
 Emerging Powers and Global Health Governance   317

domestic healthcare models remain under the sway of Western countries, rather than
the other way round.

Discussion

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

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

Conclusion

An examination of BRICS countries’ vision, institutions, influence, and material cap-

abilities shows the distinctive and positive role emerging powers can play in GHG. First,
in addition to existing domestic and international institutions, they are beginning to
establish their own stand-alone institutional structures in engaging global health. While
they have been laggards in some areas of global health agenda setting and norm devel-
opment, they have been active, and even taken on leadership roles, in many others.
Second, they have expanded their DAH programmes, which should contribute to health
system strengthening and improve people’s health in recipient countries. Also, the
pharmaceutical industry in these countries has redefined affordable drugs, dramatically
improving access to medicines for the world’s poor. Third, their approaches in conduct-
ing health diplomacy, including providing DAH as well as addressing domestic health
challenges, have enriched the ideational foundations of GHG, pointing to an alternative
model for improving global health. Compared with those of OECD countries, BRICS
countries’ DAH programmes are not so much about financial contributions as about
using the limited DAH as a way to empower recipient countries through international
cooperation. This finding has important implications for emerging powers’ ability to
engage global health even when their economies are slowing down.
That said, their roles in GHG remain generally limited, and it is still too early to view
them as a counterbalance or counterforce to industrialized countries in GHG. The DAH
from emerging powers remains dwarfed in comparison to traditional OECD donors.
Their distinctive patterns of DAH do not align well with many existing global health ini-
tiatives and projects, which may create additional silos and exacerbate coordination and
coherence problems in GHG. Furthermore, as the DAH policy structure remains condi-
tioned by the BRICS countries’ domestic health agendas, it would be unrealistic to
expect them to significantly increase their DAH anytime soon, and global health finan-
cing will continue to rely primarily on the largesse of the OECD countries. In develop-
ing and participating in global-health-related institutions, their approach remains
selective and individualistic, and they have only occasionally played the leadership role
in agenda setting and norm development. Despite the rhetoric of South-South solidarity
and efforts to form coordinated positions, it remains to be seen if they will develop the
ability to translate policy statements into actions.
A look at the ideational foundations of BRICS nations’ involvement in GHG suggests
that while they have an alternative model for GHG, most components of the model are
neither novel nor innovative, and their effectiveness remains in question. Their efforts to
promote global health agenda such as UHC and global health security may offer both
positive and negative lessons for other LMICs, but they primarily serve their domestic
 Emerging Powers and Global Health Governance   319

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

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

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Further Reading
Cox, Robert W. 1996. Approaches to World Order. Cambridge, MA: Harvard University Press.
Denburg, Avram and Kelley Lee. 2013. ‘Access to Paediatric Medicines: The Global Political
Economy of Paediatric Drugs for Children in the Developing World.’ In Global Governance
of HIV/AIDS: Intellectual Property and Access to Essential Medicines, edited by Obijiofor
Aginam, John Harrington, and Peter K. Yu, 53–81. London: Edward Elgar.
Lee, Kelley, and Adam Kamradt-Scott. 2014. ‘The Multiple Meanings of Global Health
Governance: A Call for Conceptual Clarity.’ Globalization and Health 10 (1): 28.
Moon, Suerie. 2008. ‘Medicines as Global Public Goods: The Governance of Technological
Innovation in the New Era of Global Health.’ Global Health Governance 2 (2): 1–23. http://
www.ghgj.org/Moon_Medicines%20as%20Global%20Public%20Goods.pdf.
Sandberg, Kristin Ingstad, Steinar Andresen, and Gunnar Bjune. 2010. ‘A New Approach to
Global Health Institutions? A Case Study of New Vaccine Introduction and the Formation
of the GAVI Alliance.’ Social Science & Medicine 71 (7) (October): 1349–1356.
 chapter 17

The Politics of
Gl oba l H e a lth
Agen da Set ti ng

Stephanie L. Smith and Jeremy Shiffman

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

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

Actors

WHO and member states dominated agenda setting processes for international health
cooperation from the late 1940s until the 1980s, when the World Bank and other organ-
izations also carved out prominent roles (Walt 1994; Walt, Spicer, and Buse 2009). A
proliferation of individuals and organizations—both state and nonstate—now shape
global health agenda setting.
Among these individuals are policy entrepreneurs who draw attention to problems,
link these to solutions, and take advantage of political opportunities (Kingdon 1995).
Studies of multiple issues—including surgery, alcohol harm, cervical cancer, mental
health, nutrition, family planning, maternal survival, and newborn survival—offer
evidence that the ebbs and flows of attention are shaped by the absence, presence,
and capabilities of such entrepreneurs (Schmitz 2016; Parkhurst and Vulimiri 2013;
Reichenbach 2002; Shawar, Shiffman, and Spiegel 2015; Pelletier et al. 2012; Tomlinson
and Lund 2012; Blanc and Tsui 2005; Smith and Rodriguez 2016; Shiffman 2016a).
Leaders of extraordinary stature, such as heads of state and international organizations,
are the targets of entrepreneurial efforts and sometimes become influential champions
themselves. Such high-level leadership has made a significant difference for several glo-
bal health issues. For example, former UN Children’s Fund (UNICEF) executive dir-
ector James Grant led the Child Survival Revolution during the 1980s, culminating in
the assembly at the World Summit for Children in 1990 of the largest group of world
leaders in history to commit to improving child health and survival (UNICEF n.d.). UN
Secretary General Kofi Annan championed the UN Millennium Declaration and Goals
at the end of the twentieth century, setting in motion a new development ‘supernorm’
that mobilized action on several major global health issues over the following fifteen
years (Fukuda-Parr and Hulme 2011). Subsequently, as part of efforts to accelerate progress
on UN Millennium Development Goals 4 and 5 (on child and maternal survival),
several world leaders, including the prime ministers of Norway, the UK, and Canada,
 Politics of Global Health Agenda Setting   327

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

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

Ideas

Ideas are knowledge and beliefs about what ought to exist in the world. Ideas that
motivate collective action are particularly powerful in the agenda setting process
(Finnemore and Sikkink 1998; Sabatier and Jenkins-Smith 1993). Frames (lenses
through which issues are understood) and norms (shared expectations for the
­behaviour of actors with a particular identity) are the central ideational variables in
global health agenda setting scholarship (Finnemore and Sikkink 1998; Katzenstein
1996; Snow et al. 1986).
Political actors define and portray problems in particular ways to assign blame and
responsibility (Stone 1989). Effective causal stories unify concerned actors and assign
responsibility to authorities, while muddled stories interfere with these crucial compo-
nents of the agenda setting process. For example, decades of evidence establishing
tobacco use as a major direct cause of disease and death helped to unify concerned
actors, shift perceptions of the issue from an individual to a population health problem
for which industry is culpable, and bolster the case for the FCTC (Gneiting 2016). In
contrast, alcohol control has a more complicated causal story than tobacco control, con-
tributing to its challenges in gaining traction on the global health policy agenda
(Gneiting and Schmitz 2016). Complicated causal stories have inhibited agenda setting
for other global health issues, including non-communicable diseases, surgery, mental
health, oral health, health systems strengthening, and universal health coverage
(Benzian et al. 2011; Brolan and Hill 2016; Geneau et al. 2010; Hafner and Shiffman 2013;
Jönsson 2014; Shawar, Shiffman, and Spiegel 2015; Tomlinson and Lund 2012).
Scholars have provided evidence that widely agreed upon solutions, and perceptions
that problems are severe and tractable, facilitate agenda setting (Keck and Sikkink 1998;
Snow et al. 1986; Stone 1989). Such shared ideas have helped to advance agenda setting
for polio, malaria, tobacco control, tuberculosis, maternal health, newborn survival,
sexually transmitted infections, and nutrition globally and nationally (Gneiting 2016;
Lush, Walt, and Ogden 2003; Ogden, Walt, and Lush 2003; Pelletier et al. 2012; Quissell
 Politics of Global Health Agenda Setting   329

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

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

Interests

Global health agenda setting scholars also seek to understand the ways in which interests
shape actor behaviour and whose interests prevail in the process. Interests are prefer-
ences affected by the benefits or losses that accrue (or are expected to accrue) to an actor
because of a set of conditions. Neorealist theory is premised on the notion that actors are
driven by self-interest (Mearsheimer 1994–1995). Researchers ask such questions as how
the economic and security interests of nations, and the profit motives of corporations,
influence the agenda setting process. Research strongly suggests that material interests,
including threats to national security and the economy, play significant roles in health
agenda setting at the global and national levels (Feldbaum, Lee, and Michaud 2010;
Labonté and Gagnon 2010; McInnes and Lee 2006; Ruckert et al. 2016; Rushton 2011;
Watt, Gomez, and McKee 2014). An issue is more likely to emerge on the global health
agenda if the interests of powerful actors align (Brolan and Hill 2016; Collin, Lee, and
Bissell 2002; Reich 1987).
Economic interests play central agenda setting roles for many global health issues.
Reich (1987), for example, observed that when WHO moved to prioritize essential drugs
in the late 1970s, it designed vague recommendations in consideration of the pharma-
ceutical industry’s economic interests, helping to maintain industry support for the
action. Economic interests of the pharmaceutical industry and low-income countries
shaped actor behaviour in the cases of praziquantel availability (Reich and Govindaraj
1998) and universal access to antiretroviral (ARV) drugs (‘t Hoen et al. 2011; Kapstein
and Busby 2010). In the case of praziquantel, a Korean company worked with national
governments prioritizing schistosomiasis treatment to produce and offer the drug at a
lower cost than competitors. World Bank loans helped some highly burdened countries
make the treatment widely available, though significant gaps in access remained
through the 1990s. In the case of ARVs, pharmaceutical companies doubted a market
 Politics of Global Health Agenda Setting   331

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

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

Institutions

Institutions are ‘collections of structures, rules, and standard operating procedures’ that
are relatively enduring and shape actor expectations, preferences, and behaviour (March
and Olsen 2006, 4). Aid structures, accountability regimes, and ethical standards play
such roles in the global health arena. Global health agenda setting scholars are princi-
pally interested in explaining why issues rise and fall on policy agendas; therefore,
institutional variables tend to come to the fore of analyses when they help to explain
change and fade into the background when they do not. Cases that highlight the
influence of international human rights treaties, rules governing participation in UN
processes, and trade and patent laws provide insights into the roles of institutions in
shaping the global health agenda.
Rules governing participation in processes related to the WHO-sponsored FCTC—
with some formed to include and others to exclude particular actors—offer examples of
ways in which institutions shape the agenda. First, as work to advance the FCTC began
in the late 1990s, many civil society organizations were effectively blocked from partici-
pating by the multi-year process for attaining official relations status with WHO.
Seeking broader political and technical support for the treaty, member states approved
an accelerated and expanded process for expert NGOs to attain official relations and
consultative status, bringing significant new resources to bear on the FCTC process
(Collin, Lee, and Bissell 2002). The change in rules governing consultative relations
facilitated expansion and diversification of the network of actors concerned with the
harmful effects of tobacco use. The expanded network, among other contributions, edu-
cated delegates on technical aspects of the proposal, lobbied governments, waged media
campaigns, exposed deceitful tobacco industry practices, and countered obstruction
from some governments, elevating the FCTC on global and national policy agendas
(Collin, Lee, and Bissell 2002; Lencucha, Kothari, and Labonté 2011). By way of contrast,
industry actors were formally excluded from the FCTC negotiation process, limiting
their influence to representation through third parties, such as ‘friendly governments’
(Gonzalez, Green, and Glantz 2012, 5). In addition, Article 5.3 of the FCTC and related
implementation guidelines support parties in insulating the policy process from
tobacco industry interference in accordance with national law, though selective adop-
tion of recommendations provides continuing opportunities for industry influence in
many countries (Fooks et al. 2017).
 Politics of Global Health Agenda Setting   333

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

Discussion

Existing research provides wide-ranging insights into the various factors shaping
global health agenda setting. The capabilities of actors matter, including those of
334   Stephanie L. Smith and Jeremy Shiffman

­olicy entrepreneurs, high-level champions, and networks. So do their ideas,

p
­particularly about problem definition, solutions, and causal stories. Interests are
critical, particularly security and economic concerns of powerful countries
­
and industries. And institutions—such as international law and trade regimes—
structure the process.
While many factors are influential, research indicates that several are present in most
instances of the rise to prominence of a global health issue. These include (1) a perception
that the problem is severe, (2) a clear causal story concerning why the problem exists,
(3) a perception that the problem is soluble, and (4) an expectation that public authorities
have a responsibility to address the problem. Global governing bodies and national
governments rarely allocate significant attention and resources to issues that lack one or
more of these facilitating factors.
Other factors appear to matter more under some conditions than others. For prob-
lems that affect groups such as newborn babies and adolescent girls, who have little
political power or pose no obvious security or economic risks to dominant countries,
strong champions or networks are usually instrumental. In addition, certain kinds of
ideas, such as frames aligned with international human rights norms, may take on
significance when such marginalized groups are involved. Such actors and ideas may
matter less when dominant countries or groups feel under threat, as political and
economic elites can be expected to exert power to ensure that policymakers protect
their interests.
These dynamics suggest that there may be multiple paths to prominent global
health agenda status, aligned with the different categories of the factors noted
above. Issues may rise due primarily to ideational factors, as global champions make
principle-based arguments that resources should be provided to address a problem.
Maternal survival and some neglected tropical diseases fit this pattern. Issues may
also gain prominence due primarily to interest-oriented factors, as powerful actors
understand their economic or security concerns to be under threat or perceive a
potential gain from a condition receiving attention. Ebola and SARS fit this pattern.
A combination of ideational and interest-based influences may shape the ascendance
of other issues that threaten both marginalized and powerful groups. HIV/AIDS is
an example: grassroots advocacy, policymaker fears in industrialized states, and
­pharmaceutical company desire for profit from potential drug sales all shaped its rise
to prominence as a global health issue.
Research also indicates that actors and their ideas and interests, on the one hand, and
institutions, on the other, interact to shape global health agenda setting. Institutions
such as human rights laws and trade regimes structure the agenda setting process,
favoring some issues over others. However, these are not determinative; operating
within institutional constraints, actors are instrumental in shaping whether an issue
becomes prominent. Moreover, actors are involved in reshaping these very institutions.
These observations connect to long-standing social scientific debates about the relative
roles of agency and structure in shaping social processes. Global health agenda setting
research supports the contentions of some scholars that rather than being separate,
 Politics of Global Health Agenda Setting   335

agentic and structural forces are mutually constitutive, and that both influence social
processes, including agenda setting.
This chapter synthesized research on global health agenda setting. A growing number
of studies also focus on health agenda setting at the national and subnational levels,
many with attention to the influence of global dynamics. Readers concerned with health
agenda setting processes across global and national spheres will want to be aware of both
bodies of scholarship. Among the theoretically grounded recent contributions in this
vein are analyses of the following:

• Differing beliefs among advocacy coalitions in Iran’s tobacco control arena, a study
that draws on the ‘advocacy coalition framework’ (Sabatier and Jenkins-Smith
1993), a prominent model of the policy process (Khayatzadeh-Mahani et al. 2017).
The analysis draws attention to influences of differing beliefs among pro- and anti-
shisha smoking ban coalitions in Kerman Province, weak support outside the
health policy subsystem, and autocratic governance arrangements.
• The role of national networks in three cases of health policy change in Burkina
Faso, a study that, like this chapter, considers the integrative roles of ideas, inter-
ests, and institutions (Shearer et al. 2016). Among other insights, policy reforms
are traced to effects of new donor rules in introducing different actors and ideas to
child health and malaria networks.
• The influence of actors, ideas, and subnational political contexts on agenda setting
for maternal survival in India (Smith 2014). The analysis draws attention to roles
of policy entrepreneurs, framing, and differing sociopolitical legacies in two states.
Critically, Tamil Nadu’s non-Brahmin social movement was facilitative, while
Karnataka’s developmental disparities combined with decentralized governance
structures to hinder progress.
• How gender-based violence emerged as a health issue in Nepal, integrating fram-
ing theory into Kingdon’s (1995) multiple streams model (Colombini et al. 2016).
A domestic violence bill was adopted only once policy elites framed the issue in
human rights terms, facilitating alignment of the problem, policy, and politics
streams.
• The rise of a national health insurance scheme (Rashtriya Swasthya Bima Yojana)
on the policy agenda in India, also drawing on Kingdon’s streams model (Shroff,
Roberts, and Reich 2015). The analysis shows how a resourced group of domestic
policy entrepreneurs worked with international agencies to advance the reform
effort and secure its adoption.
• How vertical birth practices among indigenous women made it onto the policy
agenda in Ecuador, a study that draws on Kingdon and the ‘punctuated equilib-
rium’ theory of the policy process (see below) (Llamas and Mayhew 2016). The
analysis draws attention to the influence of indigenous actors—rarely con-
sidered in agenda setting studies—and to the local socio-economic and polit-
ical contexts that shape actor behaviour, as well as perceptions of problems and
their solutions.
336   Stephanie L. Smith and Jeremy Shiffman

Considerations for Future Research

on Global Health Agenda Setting

Future global health agenda setting research should investigate several theoretically
grounded hypotheses and research questions that hold promise for strengthening
and adding insights to existing scholarship. Critical questions corresponding to the
categories of factors discussed in this chapter include the following:

• How does agenda setting differ for issues affecting marginalized versus elite
groups? Specifically, how does the social construction of affected groups (Schneider
and Ingram 1993) influence the process and its outcomes? Does the power of a
frame (human rights, security, public health, economics, etc.) vary by population
affected?
• How does the composition of networks (which may change over time) affect glo-
bal health agenda setting? How do diversity, representation from key stakeholder
groups, and commitment factor in? Are close-knit coalitions of like-minded actors
more effective at some tasks (e.g., establishing the severity of problems and their
tractability) and networks that form broad political alliances more effective at
others (e.g., attracting support from high-level leaders)?
• Do the agenda setting process and its outcomes vary when rules for actor partici-
pation differ? How do civil society and industry participation matter? How do
legitimacy perceptions factor into participation rules across venues?
• How does resource scarcity—increasingly a concern given the recent wave of
national populist politics in high-income settings—shape the dynamics of com-
petition among global health issues? Will such scarcity adversely affect newly
prominent issues on the global health agenda—such as universal health cover-
age—if resources become concentrated on specific initiatives targeting HIV/
AIDS, polio, Ebola, and other prominent diseases? Or have these newly prom-
inent issues carved out a secure place on the agendas of global health
institutions?

Other global health agenda setting questions that extend the scope of the analytical
framework used in this chapter include the following:

• How are advances in communications technologies, including social media,

shaping the global health agenda setting process? Are they democratizing it? If so,
to what extent, and with what effects?
• How does the agenda setting process vary when effective intervention means
engagement beyond the health sector—across multiple policy arenas? Under what
conditions and to what extent do public health–oriented networks engage other
 Politics of Global Health Agenda Setting   337

policy arenas, such as sanitation, energy, environment, and economic development?

What strategies do networks employ, and how effective are they?
• How do global- and national-level agenda setting processes affect each other? To
what extent do network factors, such as the quality of linkages between global- and
national-level actors and the extent to which framing strategies are tailored to con-
text, explain variation at the national level?

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

pressure are among the constituent elements of the politics stream. At particular junctures
the streams merge, and at their confluence windows of opportunity emerge and
­governments decide to act.
Developed by Sabatier and Jenkins-Smith (1993), the Advocacy Coalition Framework
(ACF) has also been widely employed to study the agenda setting process (Sabatier and
Weible 2007; Jenkins-Smith et al. 2014). Part and parcel of the growing literature on
roles of networks in the policy process, the ACF posits that coalitions of specialized elite
actors advocate for issues within substantively and geographically bound policy
­subsystems. Advocacy coalitions are motivated, and their strategies are guided, by
shared beliefs that tend to be highly stable but can change as a result of policy-oriented
learning or external perturbations or shocks. Divergent beliefs and preferences (dis-
cussed in terms of ideas in this chapter) form the basis for conflict among coalitions.
According to the ACF, deep core beliefs and policy core beliefs are resistant to
change, but secondary beliefs concerning details of causal stories in specific localities
and programmatic rules and procedures, for example, are narrower in scope and
more amenable to change. Contextualizing the framework’s application, policy
­subsystems and the actors that operate within them are understood to be affected
by factors exogenous to the subsystem, including relatively stable parameters
(e.g., basic constitutional, sociocultural, and resource structures) and external events
(e.g., changes in socio-economic conditions, public opinion, governing coalitions,
and other subsystems). Major policy change is hypothesized to be a product of
­policy-oriented learning, external shocks, internal shocks, or ‘a hurting stalemate’
(Sabatier and Weible 2007, 208).
Another influential agenda setting model is that developed by Baumgartner and
Jones (1993), punctuated equilibria, which postulates that the policymaking process is
characterized by periods of stability with minimal or incremental policy change, dis-
rupted by bursts of rapid transformation. Central to their policy theory are the concepts
of the policy image and the policy venue. The policy image is the way in which a given
problem and set of solutions is conceptualized. One image may predominate over a long
period of time, but it may be challenged at particular moments as new understandings
of the problem and alternatives come to the fore. Policy venues are locations at which
authoritative decisions are made and that actors target. Some actors may hold monop-
oly power but will eventually face competition as new actors with alternative policy
images gain prominence and engage alternative venues. When a particular policy venue
and image hold sway over an extended period of time, the policy process will be stable
and incremental. When new actors targeting new venues and new images emerge, rapid
bursts of change are possible. Thus, the policy process is marked both by stability and
change, rather than by one or the other alone.
In sum, scholars have contributed much to the state of knowledge concerning the
different factors shaping global health agenda setting. They can further advance under-
standing through the use of analytical frameworks such as the one presented in this
chapter and the employment of rigorous research methods, comparative designs, and
existing policy process models.
 Politics of Global Health Agenda Setting   339

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 chapter 18

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

Tine Hanrieder

Intergovernmental organizations (IGOs) form part of a complex landscape of

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

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

Power of Intergovernmental
Organizations in Global Health

Multilateral cooperation in health dates back to the international sanitary conferences

that took place between 1851 and 1938, at which state delegates developed a body of inter-
national sanitary regulations aiming to curb the transboundary spread of contagious
diseases with minimum interference with travel and trade. WHO, created in 1948 as the
United Nations’ (UN) central agency for international health work, became responsible
for the application and updating of these regulations, which were renamed the
International Health Regulations (IHRs) in 1969 (Fidler 2005; Lee 2009). WHO also
inherited surveillance, standard setting, and policy development activities from several
pre-existing international health organizations, most importantly the League of Nations
Health Organization (1921–1946) and the Office Internationale d’Hygiène Publique
(1907–1946). It thus became the central standard setter, policy adviser, and service
coordinator in international health work in the post–World War II era (Lee 2009).
Thus from the outset the work of WHO has illustrated the three ‘roles’ that IR
researchers have distinguished for IGOs (Rittberger, Zangl, and Kruck 2012, 6). As an
arena of state interaction, WHO serves as an institution in which states convene,
exchange views, and reach agreements on its policies and its (mostly non-binding)
standards for global public health (Burci and Vignes 2004). This role is mainly assumed
through the annual World Health Assembly (WHA), at which delegates from WHO’s
194 member states jointly set global health standards and agree on the budget and
priorities of WHO secretariat’s work. As an instrument of state diplomacy, WHO’s
outputs help states coordinate their measures against infectious diseases (even though
 Politics of Intergovernmental Organizations   349

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

Sources of IGO Autonomy in Global Health

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

who is entitled to refugee status and thus worthy of international protection, or by fixing
the meaning of values such as development, growth, or human rights. Importantly, this
bureaucratic authority also generates dysfunctional tendencies and thus IGO pathologies.
In particular, Barnett and Finnemore highlight IGOs’ limited ability to learn from
changes in the world for which their ingrained routines are not appropriate. IGOs are
therefore bad at learning from failure. Their tendency to react to any problem with even
more ‘bureaucratization’ means that IGOs devise new and even more expansive policies
and thus expand their influence over time. For example, the International Monetary
Fund (IMF) has repeatedly interpreted the failure of a macroeconomic stabilization
program as an indication that the program had omitted parts of the economy, and that
therefore more expansive IMF interventions and conditionalities (Barnett and
Finnemore 2004, 71) were needed.
Barnett and Finnemore centered their analysis on the IMF, the UNHCR, and the UN
Department of Peacekeeping Operations (Barnett and Finnemore 2004). Interestingly,
however, an earlier study of a health-related IGO, namely Jared Siddiqi’s monograph
about WHO’s structural evolution and the failure of its malaria eradication program of
the 1950s and 1960s, anticipated many of the claims made by Barnett and Finnemore
(Siddiqi 1995). Siddiqi’s detailed account of one of the largest single disease projects in
WHO’s history and its ultimate failure is an ideal-typical narrative of bureaucratic path-
ology. The author argues that for years the program discarded evidence that malaria
eradication was failing and ignored realities on the ground such as lacking infrastruc-
ture or insufficient political commitment. The outcome was a half-finished eradication
attempt resulting in growing resistance to DDT2 in many mosquito vectors and even
backlash in many areas where malaria returned with a more fatal impact than before the
eradication attempt (Siddiqi 1995, 123–191).
In a recent study Chorev suggests that WHO’s internal bureaucratic features crucially
shape its policies. She argues that the organization’s handling of policy conflicts between
low-income countries and high-income countries is decisively mediated by the preferences
and strategies of the secretariat (Chorev 2012). However, Chorev combines her emphasis
on the values held inside the secretariat with an analysis of the kinds of pressures exerted
on the secretariat by states. Ultimately, she suggests, it is the relative compatibility
between bureaucratic values and external demands that defines how IGOs formulate
their policies, or in other words, bureaucratic authority is exerted within the limits set
by member states.
The nature and institutional design of these limits is at the center of the second
main approach to IGO autonomy and part of the rational institutionalist approach to
global governance, namely principal-agent (PA) theory. It analyzes the contractual
arrangements through which states delegate competencies to IGOs and the instru-
ments through which states monitor and control the behavior of IGOs (Hawkins et al.
2006). From this perspective, the delegation of authority to IGOs, including discre-
tion in the handling of their tasks, is rationally chosen by states that seek to save time
and create synergies by working through IGOs. However, states also use a variety of
monitoring and sanctioning techniques to make sure that IGOs do not act against
 Politics of Intergovernmental Organizations   351

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

‘normative’ focus of its mandate as a consultant and coordinator had hampered its
ability to act in the first place (McInnes 2015). Indeed, post-Ebola reform efforts such as
endowing WHO with emergency funds and a standby emergency workforce (see
“Inter-organizational Dynamics of Change”) make it clear that states keep supporting a
special discretionary role for WHO in the face of unforeseen events. This institutional
dynamic in the domain of global health security also sheds a new light on the broader
question of IGO agency in times of crisis. Global health scholars have accounted for the
empowering effect of crises on IGOs by combining insights from PA theory and critical
security studies, showing how the ‘securitization’ of health threats creates demand for
IGO authority (Hanrieder and Kreuder-Sonnen 2014; Kamradt-Scott 2015). These
insights open up new avenues for research into the ways in which phases or instances of
exceptionalism affect IGO authority in various issue areas of global governance
(Kreuder-Sonnen 2016).
A second contribution to PA theory that is also based on research on WHO points to
a thus far neglected source of agency slack: the problem that in many cases WHO does
not behave as one, but as many, actors. Studies of WHO’s performance in the domains of
primary healthcare and HIV/AIDS suggest that the organization often fails to be
responsive to its ‘principals’ (member states in PA terminology), because different parts
of the organization are working at cross-purposes. One reason is the exceptionally
strong role of WHO’s six regional offices, which were granted a special status in the
WHO Constitution and have consolidated their position ever since (Hanrieder 2015a).
The regional office’s poor coordination with WHO’s central secretariat has been criti-
cized throughout the organization’s history, most recently during the 2014 Ebola
­epidemic, when the regional office of the African region barely collaborated with
WHO’s secretariat or with external agencies such as the US Centers for Disease Control
and Prevention (CDC) (Sack et al. 2014). This disconnect between WHO’s secretariat
and its regional offices led Graham to conceptualize WHO as a ‘collective agent’, a
phenomenon previously not foreseen by PA theory (Graham 2014). Hanrieder also
stresses this regional dimension of ‘fragmentation’ of the WHO actor and adds a second
dimension, which is the organization’s growing dependence on extra-budgetary
donations. This leads to the emergence of separate, donor-sponsored programs with
relative autonomy from the WHO director-general and thus exacerbates the problem of
fragmented agency (Hanrieder 2015a). The incoherence of ‘the’ WHO agent leads to
puzzling irregularities in WHO’s behavior that PA theory cannot account for. One is
self-sabotage or ‘mission shrink,’ which happened to WHO’s Global Programme on
AIDS in the late 1980s and early 1990s (Hanrieder 2014a). Another is a lack of ‘faithful-
ness’ to state demands because the fragmented agent is incapable of executing them
(Graham 2014). These studies expose PA theory’s difficulty in handling situations in
which IGOs cannot be conceptualized as coherent actors. Before discussing the
question of how coherent patterns of change can be distilled from such complex con-
stellations, the following subsection explores whether and how IGO autonomy from is
matched by IGO influence on member states.
 Politics of Intergovernmental Organizations   353

Sources of IGO Influence

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

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

Dynamics of Organizational Change

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

Health IGOs between Forces of Stability

and Pressures for Reform
With IGO power comes responsibility-and contestation (Zürn, Binder, and Ecker-
Ehrhardt 2012). This is also true for the IGOs engaged in global health, which have often
 Politics of Intergovernmental Organizations   355

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

The second source of change, normative pressure through public campaigns, naming
and shaming, or persuasion strategies, has also long been an important driver of new
developments in health-related IGOs. Civil society actors, especially when organized in
transnational advocacy coalitions (Keck and Sikkink 1998), have repeatedly targeted
health-related IGOs and also won some important victories. For example, population
control policies promoted by the Rockefeller Foundation and IGOs such as the UN
Population Fund have changed considerably in response to public pressure. While the
1960s and 1970s were marked by extremely intrusive measures—for example in India
with practices such as forced sterilization and arrests of people who opposed population
control—public protests against these practices did lead to change. The International
Conference on Population and Development, held in Cairo in 1994, formulated
­so-called reproductive rights, such as access to family planning and education, to ensure
that population policies do not infringe on human rights and especially women’s health
(Connelly 2008). Similarly, in the 1970s transnational activists successfully pushed for a
WHO/UNICEF code regulating the marketing of breast milk substitutes (Sikkink 1986).
Nowadays, ever more civil society groups, such as the People’s Health Movement, are
making WHO politics more transparent, and NGOs such as Health Action International
challenge contentious outputs such as the intellectual property regime. Powerful
movements, especially the campaigns of AIDS advocacy groups, have indeed helped to
transform global pharmaceutical markets to ensure broader access to life-saving anti-
retroviral medicines (Kapstein and Busby 2013). Likewise, aspects of the WTO’s TRIPS
Agreement have been refined to allow for public health safeguards, also due to pressure
from civil society groups (Sell and Prakash 2004).
However, just like responses to material pressure, IGO responses to normative
campaigns are far from linear. Not all normative campaigns find resonance in IGOs. For
example, the ‘Independent WHO’ campaign, asking for the WHO to take a stronger
stance toward the International Atomic Energy Agency (IAEA) when it comes to
identifying and combating hazards of nuclear energy, is hardly heard, in spite of recur-
ring nuclear catastrophes.3 In addition, IGO responses to normative demands are also
path dependent. They depend on IGO procedures for processing normative demands,
at both legal-institutional and cognitive levels. Legal path dependence has played out,
for example, in the case of the UN’s role in the 2010 cholera outbreak in Haiti. Pillinger
and colleagues show how existing biases in international law shield UN organizations
from demands for accountability (Pillinger, Hurd, and Barnett 2016). In spite of
overwhelming evidence that cholera was brought to Haiti by UN peacekeepers, the UN
has avoided any legal redress-or even open investigation of the epidemic (Frerichs
2016). Existing biases in international law, especially UN immunity, combined with
Haiti’s vulnerability as an utterly dependent recipient of foreign aid, have produced a
blatant disregard for the harm done to Haitians (Pillinger, Hurd, and Barnett 2016).
Beyond formal immunity, IGOs have the means to divert demands for accountability.
Not only in the UN Haiti case, but also in other IGOs such as WHO, ex post reviews of
IGO failures are often performed by organs that are only partially autonomous from the
IGO under scrutiny. A case in point is WHO’s investigation of its handling of the 2009
 Politics of Intergovernmental Organizations   357

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

Inter-organizational Dynamics of Change

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

sans Frontières or one of the various public-private partnerships for health that were
created around the turn of the millennium (Bull and Mcneill 2007, 66). IGOs are both
rivals of and participants in many of these partnerships. For example, the Global Fund
to Fight AIDS, Tuberculosis and Malaria (GFATM, created in 2002) is governed by an
executive board that also gives a say to representatives of IGOs, including the World
Bank, WHO, and UNAIDS (although these IGO representatives only participate as
non-voting members, unlike states, NGOs, and philanthropic board members5).
Another major global health partnership, GAVI (Global Alliance for Vaccines and
Immunization, created in 2000), has a similar board structure, although in this case
IGOs have the same status as representatives of states, industry, NGOs, or independent
individuals.6 This growing inter-IGO competition has raised questions about both the
reasons for and the consequences of competition between IGOs.
The reasons that states (and donors) choose to shift their support to new or different
organizations, often while diminishing their support for those IGOs that they used to
work with, are differently interpreted. One main functional reason identified in the IGO
literature is states’ dissatisfaction with the performance of an IGO and thus the impression
of states and donors that the institutional status quo is inefficient. This impression is
often tied to new developments in the international environment (e.g., the emergence of
new diseases), in response to which the old IGOs do not have the right means and
procedures (Morse and Keohane 2014, 390). Still, not all dissatisfaction leads to
immediate exit. Rather, it is stressed that states are reluctant to make such changes due
to sunk investments in existing IGOs and the switching costs that accompany exit. Thus,
dissatisfaction must reach a certain threshold for states to actually withdraw from an
IGO they used to work with (Jupille, Mattli, and Snidal 2013).
However, a purely functional account does not capture the entire problem of exit
from IGOs. Perceptions of an IGO’s functionality differ. While some states may herald
the legal power of the WTO and its intellectual property regime, others may regard this
as a health hazard. Or while some states may prefer targeted, vertical disease campaigns
as they are promoted by the GFATM, others may favor more integrated approaches to
strengthening health systems that are part of WHO’s policy portfolio. Therefore, it also
matters who of several contending actors has the means to actually choose exit, such as
because a state can do without the collaboration of its partners within an established
IGO, or because it has the means to establish and strengthen a rival institution. Usually,
functionality and power concerns will interact in decisions about exit.
This interaction is illustrated by a prominent example of exit in the global health
domain, namely the history of the Joint United Nations Programme on HIV/AIDS
(UNAIDS). AIDS, which emerged in the 1980s, was initially dealt with by a special unit
inside WHO, the Global Programme on AIDS (GPA). In its early years the GPA was
supported by a strong coalition of activists, NGOs, and Western donor states. It attracted
enormous funds, which it administered directly with donors and recipient countries
instead of working through WHO’s regional offices. Yet over time internal and external
resistance to the GPA grew. From inside WHO, a leadership change led to a greater voice
for WHO’s regional offices and to measures that aimed to rein in the relative autonomy
 Politics of Intergovernmental Organizations   359

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

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

Conclusion

IGOs continue to play an important part in the provision of global health governance.
They are not only instruments of powerful member states, but also authorities in their own
right, shaping the meaning and practice of healthcare around the globe. States and social
actors will keep turning to IGOs when seeking support in the face of old and new health
challenges; in doing so, they will often rely on the cognitive tools and political categories
provided by IGOs. The different research strands reviewed in this article underline the
dynamism of health-related IGOs, but at the same time demonstrate the continued effects
of early institutional choices made in the nineteenth and twentieth centuries. The result is
a complex interaction between institutionalized patterns and demands for change that will
continue to stimulate innovation in global health and IGO research.
 Politics of Intergovernmental Organizations   361

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

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

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 chapter 19

Ci v il Societ y a n d
Gl oba l H e a lth
Politics

David M c Coy and Joseph Gafton

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

The Concept of Civil Society

Civil society is typically understood in two ways. First, as a collection of actors that share
the distinction of being neither governmental nor a business or other form of commer-
cial organisation. Second, as one of three spheres of society, alongside the state and the
market. While seemingly simple and straightforward, both understandings of civil
society are more complex.
368   David McCoy and Joseph Gafton

To begin with, civil society actors are extremely diverse in nature. They may include
professionalised non-governmental organisations (NGOs), charities, universities,
independent research institutions, think tanks, professional associations, trade unions,
cooperatives, faith-based organisations, consumer groups, community-based sports
and leisure clubs, and more loosely organised social movements. Furthermore, they are
extremely diverse in terms of their functions, size, membership, and geographic affili-
ation (McCoy and Hilson 2009).
The governmental and private sectors are also diverse in nature. The former
includes the executive, legislative, and judicial branches of government, as well as
other organs of the state such as the army, the police, and any number of quangos or
parastatal agencies. The latter range from tiny micro businesses to large global con-
glomerates and cut across the financial, manufacturing, agricultural, extractive,
retail, and service sectors.
Any simplistic distinction amongst the state, markets, and civil society also masks the
fact that actors may cut across the three spheres. For example, some NGOs that have the
appearance of being part of civil society may have been established and funded by
governments or private corporations to act as their agents. Such NGOs have been clas-
sified as GONGOs (government-organised NGOs) and BINGOs (business-interest
NGOs) to make the point that they are not true civil society actors. This raises questions
about the legitimacy and independence of civil society actors. Clearly there is a distinc-
tion between broad-based and inclusive civil society actors with a public interest mis-
sion and those that exist primarily to serve the interests of governments or private actors
(Doyle and Patel 2008).
The three spheres of the state, markets, and civil society are also highly intercon-
nected and coexist in different ways depending on the social, political, and economic
context of any given society. For example, in authoritarian countries ruled by dicta-
torships, civil society actors may be weak and the sphere of civil society may be small
relative to that of the state, but where democracy is strong, civil society actors may act as
a check and balance to the power of the state. Similarly, the character, size, and influence
of the market in society will depend on the sociopolitical context. For example, the way
in which tax systems are designed and implemented and the way in which legal and
judicial systems regulate corporate activity and electoral processes will influence the
relative power of the corporate sector and its ability to influence public institutions or
democratic processes. Similarly, in societies with unrestrained capitalism and unregu-
lated markets, private interest groups have a greater opportunity to flourish at the
expense of the general public.
Civil society is also political. Kaldor (2003, 585) describes it as an arena in which indi-
viduals and groups ‘negotiate, argue, struggle against, or agree with each other through
a variety of associations and organisations’, while Scholte (2011) describes it as a space in
which voluntary organisations interact to shape the rules of society. Tarrow (1994) even
describes social movements as the central bearers of democratising pressures within
states, noting their role in the overthrow of dictatorships in Latin America and Eastern
Europe.
 Civil Society and Global Health Politics   369

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

Neoliberal Globalisation and

Contemporary Global Health Politics

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

In parallel, the enablement of transnational corporations and wealthy elites to evade

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

Civil Society and the Politics

of Global Health

This section looks at three key aspects of global health politics: first, the ideological
differences between comprehensive and selective primary healthcare; second, the
emergence of new actors in the global health landscape; and third, the corporate capture
of civil society.
 Civil Society and Global Health Politics   371

Comprehensive and Selective Approaches to Health

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

helped plan the Alma-Ata conference (Rifkin and Walt 1986). The Jubilee 2000
­campaign—one of the largest transnational civil society mobilisations of the twentieth
century—provides another example of civil society’s support for CPHC and a fair inter-
national economic order; it campaigned for the cancellation of illegitimate debts that
had paved the way for the imposition of SPHC through SAPs and were responsible for
devastating the lives of hundreds of millions of people. Today, the Peoples Health
Movement (PHM), a global alliance of civil society organisations (CSOs) that was
established in 2000 to reaffirm the principles of Alma-Ata, is an example that empha-
sises the importance of social and political activism to improved health (Narayan 2006;
People’s Health Movement 2000).
Civil society actors were also involved in establishing SPHC as a countervailing
approach to CPHC. In particular, the Rockefeller Foundation played a key role by,
amongst other things, sponsoring an international health and population development
conference in 1979 that advanced the case for SPHC (Birn and Fee 2013). There was also
support from parts of the scientific and medical community that favoured the apolitical
and technological emphasis of SPHC.
Perhaps more importantly, SAPs and the World Bank’s health sector reforms estab-
lished an NGO sector that would come to have a vested interest in supporting SPHC.
This came about as a result of NGOs being funded to deliver the services of SPHC and
fill other gaps left by a shrinking state (Ryan 1999; Dart 2004; Cooney 2006). As a result,
a professionalised and large international NGO (INGO) sector grew in the 1980s.
INGOs are now a ubiquitous presence in many health systems across the world, but
especially in developing countries, where they receive a substantial proportion of
development assistance for health (DAH).
However, some scholars argue that this ‘NGO-isation’ of development assistance has
inhibited and even undermined other forms of civil society, including social movements
that seek to improve health through socioeconomic development and political struggle
(Eikenberry and Kluver 2004). According to Chandhoke (2009), professionalised
NGOs, many based in the global North, have replaced local political agendas with
externally imposed plans and projects. A more critical perspective is that the profes-
sionalised NGO sector helps ‘to protect the legitimacy and hegemony of the neo-
liberal project’ (Carroll and Jarvis 2015, 288) by softening or containing dissent
(Fine 2002; Harriss 2002) and depoliticising issues such as the illegitimate and unfair
aspects of SAPs.
The tension between SPHC and CPHC illustrates how CSOs in the global health
sector are made up of a range of actors with diverse ideologies and positions with respect
to the political economy of health. According to Sparke (2009), CSOs may be catego-
rised into three groups depending on their relationship to neoliberalism: CSOs that act
as agents of neoliberalism are described as ‘market fundamentalists’, while ‘market
foster-care’ CSOs act to mitigate the deficiencies and harms of neoliberalism, and
‘market failure’ CSOs oppose the neoliberal political and economic arrangements
that produce poverty, inequality, and underdevelopment. Similarly, Scholte (1999)
distinguishes between ‘conformists,’ who uphold and reinforce existing norms; ‘reformists,’
 Civil Society and Global Health Politics   373

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

Global Health Governance and the Rise of New Actors

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

behalf of private foundations, corporations, and financial institutions). Overall, member

states contribute only 51 per cent of total voluntary contributions (WHO 2016b). In the
case of GHPs, NSAs are at ‘the decision-making table’, more or less as equal partners of
governments and the UN.
However, the rising influence of civil society in GHG is socially patterned and
strongly influenced by the effects of neoliberal globalisation, as described previously.
For example, the pre-eminent position of the BMGF reflects the immense concentration
of global wealth and the ability of super-elites to shape global narratives, policies, and
programmes.
There is also a bias towards certain civil society actors being able to participate in
GHG. For example, although any civil society actor can in theory enter into ‘official
relations’ with WHO and be allowed to attend the World Health Assembly and petition
the director-general to table resolutions and items for discussion (WHO 1987), the
prohibitive cost of travel and accommodation in Geneva limits participation mostly to
professionalised INGOs from high-income countries that are well funded by donor
governments, private foundations, or the corporate sector.
Similarly, while GHPs appear to enhance civil society participation in global
­gov­ern­ance in general, a study of eighteen prominent GHPs found that CSOs only occu-
pied about a tenth of all seats—far less than the private sector actors, who occupied a
quarter of all seats (Storeng and De Bengy Puyvallé 2018). Furthermore, the study found
that most civil society representatives were drawn from the global North and that only 7
out of 274 seats across the eighteen GHPs were held by individuals representing ‘patients’
or ‘affected communities’ in low- and middle-income countries.
Storeng and De Bengy Puyvallé (2018) also found that behind the rhetoric of partner-
ship, the role of civil society was mostly limited to supporting the implementation of
GHP-led programmes (and their emphasis on narrow and selective services and
technologies) or to lobbying and advocating on behalf of those same partnerships. Only
a minority of GHPs described the role of CSOs as being to question and shape decision-
making or to play a transformative role in power structures. Civil society has thus been
co-opted to represent GHPs rather than to hold them to account.
The tendency of GHPs to focus on one or a handful of diseases or technologies also
means that a large segment of civil society actors in global health tend to reinforce
the narrow, apolitical, and technocratic values of SPHC. Furthermore, both the
BMGF and GHPs reflect a ‘new philanthropy’ that embraces the application of busi-
ness techniques and market competition to the social domain of health (McCoy and
McGoey 2011). These include the use of performance-based funding models by
­donors and the characterisation of charities and NGOs as ‘investment vehicles’ that
demonstrate their value in terms of quantifiable social returns. Consequently, a top-
down and short-term, results-driven approach has been reinforced across civil
­society, displacing actors that emphasise bottom-up empowerment, cooperation,
and longer-term institution building. As CSOs compete with each other and strive to
prove their value to donors, they become less responsive and accountable to the
­communities they serve.
 Civil Society and Global Health Politics   375

Corporate Capture of Civil Society

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

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

Conclusion

Discussions about the role of CSOs in global health more often than not focus on their
functions and comparative advantages vis-à-vis the state and market. Often civil society,
government, and the private sector are presented as the separate legs of a stool upon
which effective GHG and vital cross-national or inter-sectoral alliances are established
(Smith, Buse, and Gordon 2016). In this tripartite conceptualisation of governance, civil
society actors are often viewed as ‘gap fillers’, occupying spaces that have been vacated by
the state or neglected by the market.
Civil society is also often characterised as providing a perspective that is different
from the state or market. For example, Horton eulogises civil society actors for
­providing ‘essential voices in discordant global conversations that are often dominated
by risk-adverse multilaterals, corrupt governments and neo-colonial donors’ (Horton
2016). This perspective is often accompanied by an implicit assumption that civil society
 Civil Society and Global Health Politics   377

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

tend to either represent powerful and hegemonic interests (Bebbington, Hickey, and
Mitlin 2008) or limit the degree of debate about policies and programmes so that
existing power relations are not challenged. Critically, the funding of CSOs by private
foundations, donor states, and corporations has resulted in certain NGOs, often
headquartered in the global North, dominating the civil society space at the global level.
Civil society actors with a more progressive and transformative agenda are less visible
and lack the funds and opportunities to influence policy.
The national dimension to global health politics is also important. The capacity for
large segments of the world’s population to influence global policy through their
governments is curtailed not just by the shrinkage of sovereign state power but also by
the capture or corruption of democratic institutions by powerful and wealthy actors.
Thus, while there have been many progressive civil society campaigns on a wide range
of issues, unbalanced power relations and democratic deficits prevent many of the
injustices and social problems of globalisation from being effectively addressed (Ortiz
et al. 2013).
As far as the structures of GHG are concerned, a key challenge for ensuring a more
democratic and accountable system would include restoring WHO’s status as a global
health authority with a mandate to act as a global public institution serving the needs of
all peoples. While PPPs have been viewed as a mechanism to do this, others question
whether they amount to a semi-privatisation and commercialisation of the UN system
(TRAC 2000; Richter 2003).
The restoration of WHO’s independence and integrity as an intergovernmental tech-
nical agency would require several internal reforms and improvements in management,
but crucially, it would require changes to the way WHO is financed, the removal of all
conflicts of interest with NSAs that have commercial or narrow interests, and the
establishment of mechanisms by which CSOs with broad-based public-interest
­missions can both scrutinise and support WHO.
Another challenge is curtailing the power of corporations. The importance of this is
clear from the scale of harms posed by tobacco, junk food, tobacco, and overpriced
medicines, as well as by the willingness and ability of oil and weapons companies to
perpetuate global warming and armed conflict. Civil society actors will need to play
an important role in protecting populations from the harms caused by corporate behav-
iour, just as they did in restricting the damage caused by tobacco and milk powder
companies (Mamudu and Glantz 2009; Lencucha, Kothari, and Labonté 2011; Collin,
Lee, and Bissell 2002; Allain 2002; Lee 2010) and in pushing back against pharmaceut-
ical monopoly rights that prevented access to antiretroviral treatment for people living
with HIV/AIDS (Smith and Siplon 2006; ‘t Hoen et al. 2011).
But the size of the challenge of overcoming corporate power and correcting the global
democratic deficit is considerable. An open-ended intergovernmental working group
established by the UN to work on an international legally binding instrument to regulate,
in international human rights law, the activities of transnational corporations and other
business enterprises (Office of the United Nations High Commissioner for Human
Rights 2014) offers one mechanism by which the rules of global finance and trade can be
rewritten to reduce inequality, promote health, and protect the environment.
 Civil Society and Global Health Politics   379

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

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

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 chapter 20

The Role of th e
Busi n ess Sector i n
Gl oba l H e a lth
Politics

Kelley Lee and Julia Smith

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

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

Definition of the Business Sector

in Global Health

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

Box 20.1 Selected Types of Organisations in the Business Sector

A company or firm is defined as a commercial organisation that operates on a for-profit

basis to sell goods or services to consumers. The most common forms of companies are:
sole proprietorship—a business owned by a single individual who is legally responsible
for its operations.
partnership—a business owned by two or more individuals who are legally collectively
responsible for its operations.
corporation—a business owned by shareholders according to the percentage of stocks or
shares held.
Sole proprietorships and partnerships do not have legal existence apart from the owners.
Corporations do have legal status, which is separated from owners as a protection from
direct financial liability. While sole proprietorships and partnerships are the most common
forms of companies, corporations are the most relevant to global health politics.
 Business Sector in Global Health Politics   389

associations; chambers of commerce; legal, accounting, and public relations firms;

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

The Increasing Role of the Business

Sector in Global Health

The history of international health cooperation, dating from the mid-nineteenth century,
is closely intertwined with measures to protect powerful interests within the business
sector. The fourteen International Sanitary Conferences, held from 1848 to 1938 to agree
on shared standardised measures to control the spread of certain epidemic diseases,
failed to reach agreement on some practises (e.g., quarantine) because of their potential
interference with commercial shipping. As Aginam (2005, 62) writes,

Ignorance of the aetiology of cholera, which polarised delegates at the 1851 confer-
ence, breathed new life into the ancient debate between the public health theories of
‘miasism’ and ‘contagionism’ as modes of transmission of disease. The divergent
views expressed by delegates deeply interlocked with the overall commercial interests
of participating countries….Quarantine, whether at the national or international
level, were going to hurt their shipping interests.

By the early twentieth century the potential benefits to American capitalism from inter-
national health cooperation were an important factor behind the birth of industrialist-led
390   Kelley Lee and Julia Smith

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

Collective Action to Regulate Health-Harming Industries

The marked rise in non-communicable diseases (NCDs) (e.g., hypertension, cancers,
coronary heart disease) since the late twentieth century has been widely associated with
profound changes in human diets, lifestyles, and environments on a worldwide scale.
These changes in turn have been attributed to ‘late stage capitalism’, characterised by
the dominance of large TNCs, increased socio-economic inequalities, and large-scale
environmental degradation. The business sector has been studied as a major driver
of this rapid and widespread epidemiological transition, most directly through
­market-driven changes in the production and consumption of health-harming products,
leading to the formation of global value chains, greater economies of scale, downward
pressures on input costs and pricing, and intensified marketing and promotion (e.g.,
Freudenberg 2014). The resultant ‘industrial epidemics’ (Moodie 2013) or ‘sick societies’
(Stuckler and Siegel 2011) have prompted efforts to strengthen regulation of these indus-
tries to protect population health. The ensuing clash between public health advocates
and corporate interests has become a central battleground in global health politics.
One of the most prominent of these clashes has been the ‘tobacco wars’, waged since
the 1960s, when the scientific evidence about the harmful health effects of smoking
began to be widely accepted (Brandt 2007). As governments in industrialised countries,
the traditional markets of tobacco companies, began to adopt stronger regulation,
resulting in a gradual but steady decline in consumption, the industry turned to ‘emer-
ging markets’, largely in low and middle-income countries (LMICs). The pursuit of new
 Business Sector in Global Health Politics   391

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

associations) called for an alternative strategy in 2012, targeted at eliminating ‘negative’

and promoting ‘positive’ drinking patterns (ICAP n.d.). ICAP also argued that producers
are ‘equal stakeholders’ who should be involved in formulating global alcohol strategies.
There is also evidence of the alcohol industry’s strategic use of ‘harm reduction’ as a
tactic to fend off stronger national regulation and collective action on the issue
(McCambridge et al. 2014). Given evidence of the industry’s ‘producing scholarly publi-
cations with incomplete, distorted views of the science underlying alcohol policies;
pressuring national and international governmental institutions; and encouraging col-
laboration of public health researchers with alcohol industry–funded organisations and
researchers’ (Jernigan 2012), more than five hundred public health professionals, chief
scientific officers (CSOs), and researchers published a statement of concern addressed
to WHO Director-General Margaret Chan, highlighting the weak provisions and
enforcement mechanisms embedded in ICAP’s strategy (Babor et al. 2013). Heeding
calls to resist industry influence, similar to the approach taken towards the tobacco
industry, Chan responded that, ‘[i]n the view of WHO, the alcohol industry has no role
in the formulation of alcohol policies, which must be protected from distortion by
commercial or vested interests’ (2013, f1889).
While regulating tobacco use at any level, and alcohol at excessive levels, is widely
recognised as necessary to protect against health harms, the necessity to consume food
poses a different regulatory challenge. Concerted efforts to collectively regulate the
health impacts of the food sector date from the 1980s, when CSOs campaigned on the
marketing of breast milk substitutes, notably in LMICs. Food manufacturers targeted
new mothers using, for instance, free samples, sales staff dressed as health workers, and
other unethical practises (Zelman 1990). The consequent rise in formula feeding
throughout the developing world was linked to increased infant morbidity and mortal-
ity, due to parents’ limited access to clean water, knowledge of safe feeding practises, and
the relatively high cost of formula (Sethi 1994). A coalition of CSOs, the International
Baby Food Action Network, formed to campaign against manufacturers, notably Nestlé,
prompted the adoption of the WHO-UNICEF International Code of Marketing of
Breastmilk Substitutes in 1981 (Zelman 1990). The campaign gained the broad support
of church groups, health professionals, celebrities, and politicians, and generated sub-
stantial negative public opinion for the companies involved. At the time, the code was
heralded as the culmination of a successful campaign against ‘Big Food’. After initially
arguing that the industry was only required to abide by relevant national policies, a
stance that allowed manufacturers to exploit weak regulatory environments in many
LMICs (Lee 2010), Nestlé stated that it would abide by the international code. Since the
1980s, however, the voluntary nature of the code has limited the capacity of CSOs to
monitor corporate activities, and official endorsement by only thirty-seven countries by
2014 has weakened its regulatory effectiveness (Balch 2014). In 2010 five hundred viola-
tions in forty-six countries were recorded (Kean 2014).
Since the 1980s efforts to regulate the food industry have become central to global
health politics. Accelerated globalisation since the late twentieth century has led to fun-
damental changes to the production and consumption of food worldwide, from ‘plow to
 Business Sector in Global Health Politics   393

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

Contributions to the Public Interest

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

regulation while enhancing the legitimacy of the business sector as a participant in

global health governance. The strategic engagement by corporations in activities related
to the public interest has been especially important for the tobacco industry. By the late
1990s revelations through whistleblowers, litigation, and the public disclosure of
internal documents made tobacco companies amongst the least trusted and most nega-
tively perceived by the public (Chaiton, Ferrence, and LeGresley 2006; Moodie et al.
2016). Along with documented evidence of, for example, industry knowledge of the health
harms caused by its products, manipulation of nicotine to maximise addiction, and tar-
geting of children and other vulnerable populations, industry strategies to undermine
research and policy on tobacco and health were also revealed. By the 1990s, in a context
of deep public concern over its activities (Action on Smoking and Health 2001), the
tobacco industry attempted to regain public trust. Alongside efforts to donate to public
causes such as HIV/AIDS (Smith, Thompson and Lee 2016) and the environment,
tobacco companies initiated efforts to designeduced-harm products. The industry had
introduced cigarette filters in the 1960s and ‘light’ and low-tar cigarettes in the 1960s and
1970s to allay health concerns. All have subsequently been shown to have no impact
on reducing health risks. During the 1980s and 1990s TTCs invested in research and
development on a ‘safer cigarette’ but then abruptly cancelled these efforts for fear of
increasing the risk of legal liability for their existing products (Moodie 2013).
Since the late 2000s ‘harm reduction’ has been the focus of the tobacco industry’s
investment in electronic nicotine delivery systems (ENDS), led by electronic cigarettes
and heat-not-burn products. These ‘next generation’ devices have since become central
to the political repositioning of TTCs. In 2017 Philip Morris International (PMI)
announced its manifesto for ‘designing a smoke-free future’ of ‘less harmful’ products
because ‘[s]ociety expects us to act responsibly’ (PMI 2017). This was followed by the
launch of the Foundation for a Smoke-free World, headed by former director of the
WHO Tobacco Free Initiative (TFI) Derek Yach (2017: 1809), who wrote: ‘Philip Morris
International has committed to making cigarettes obsolete and is working to internally
shift resource allocations and external engagements towards this goal. Independent,
unbiased research on the harm reduction potential of alternatives to cigarettes can both
inform their activities towards this goal and provide data relevant to regulators’.
Similarly, British American Tobacco (BAT) stated: ‘It’s simple; we want to reduce the
public health impact of our products’ (BAT 2017). As well as potentially repairing public
reputations, ENDS serves an important political strategy by enabling TTCs to reassert
policy influence. As stipulated under the FCTC article 5.3, signatory states must take
measures to prevent tobacco industry interference in health policy. Buying up and then
working through ENDS manufacturers, tobacco companies may circumvent such
restrictions. For example, the UK Vaping Industry Association (n.d.) describes itself as
established ‘in the political arena, with the public health community and with the media,
as part of our mission to build stakeholder-wide confidence in the products we manu-
facture, supply and retail, so that we can convince every smoker that switching to a vape
could positively change their life’. The London E-Cigarette Summit, held annually since
2014, is described as ‘a neutral environment for scientists, policy makers, medical and
 Business Sector in Global Health Politics   395

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

In global health, a key form of CSR has been public-private partnerships (PPPs),
defined as ‘a collaborative relationship which transcends national boundaries and
brings together at least three parties, amongst them a corporation (and/or industry
association) and an intergovernmental organisation, so as to achieve a shared
­health-creating goal on the basis of a mutually agreed division of labour’ (Buse and Walt
2000, 550). Most global health initiatives formed since 2000—including the Global
Fund to Fight AIDS, Tuberculosis and Malaria (the Global Fund), Global Alliance for
Vaccines and Immunization (GAVI), and Global Polio Eradication Programme (PEI)—
are PPPs. As WHO director-general Brundtland (2002) stated, ‘In a world filled with
complex health problems, WHO cannot solve them alone. Governments cannot solve
them alone. Nongovernmental organisations, the private sector and Foundations cannot
solve them alone. Only through new and innovative partnerships can we make a differ-
ence. Whether we like it or not, we are dependent on partners to bridge the gap and
achieve health for all’.
The pharmaceutical industry has led engagement in global health PPPs, focused on
the central challenge of how to make essential medicines affordably accessible to all who
need them (see Moon in this volume). This long-standing problem was recognised by
the first WHO Model List of Essential Medicines in 1977, adopted to rationalise national
policies and promote health equity (Laing 2003). The list continues to be updated bien-
nially, with 155 countries creating national lists of essential medicines in 2016. While the
more rational use of limited health resources in low-income countries would seem
uncontroversial, the pharmaceutical industry became concerned that such measures
would restrict sales in these growing markets. What medicines were included on or
excluded from the list impacted government health budgets. By the 1980s attention had
shifted to reviewing intellectual property rights (IPRs) as a barrier to affordable access to
patented drugs. In response, the industry lobbied the US government to withhold
voluntary contributions to WHO, signalling the beginning of long-standing tensions
between the private interests of drug patent holders and the public interest of increasing
access to medicines (Brown, Cueto, and Fee 2006). In 1986 the Intellectual Property
Committee (IPC) was formed by twelve US-based pharmaceutical companies, to lobby
for a comprehensive agreement to protect IPRs during negotiations to create the World
Trade Organization (WTO). The IPC concluded that it ‘got 95 percent of what it wanted’
in the resultant Trade-Related Intellectual Property Rights (TRIPS) Agreement (Buse,
Mays, and Walt 2012, 163). Civil society organisations, patient advocacy groups, and
governments of many LMICs opposed the agreement, arguing for affordable access to
drugs such as antiretroviral treatment for HIV and AIDS. It was during this period of
political conflict between pharmaceutical companies and public health advocates that
PPPs were rapidly formed. The precise number of global health–related PPPs estab-
lished is unknown, given varying definitions and incomplete data, but they are believed
to number in the thousands (Ruckert and Labonte 2014).
For the business sector, the political and economic motivations for engaging in CSR
activities are to fend off binding regulation, improve corporate reputation, advance
new markets, and ultimately generate higher profits (Droppert and Bennett 2015).
 Business Sector in Global Health Politics   397

For governments, major donor agencies, and international organisations, as well as

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

contraceptive manufacturers sold their products at affordable prices, handled distribution,

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

Participation in Global Health Governance

Participation by the business sector in the governance role of international organisa-
tions has arguably been the most significant shift in global health politics since the late
twentieth century. In addition to being ‘rule-takers’, subject to the authority of national
and international regulatory bodies, the business sector may be acting increasingly as
‘rule-makers’ by contributing to formal decision-making processes, as well as influen-
cing decision-making through less formal processes of norm shaping (Suzuki and
Moon 2016). The extent to which this is desirable and the implications for global health
politics have elicited growing scholarly debate.
One important area of regulation is the adoption of international product standards,
governed by the International Organization for Standardization (ISO), to protect the
health and safety of consumers. In principle, standards setting should be carried out
independently of commercial vested interests and be evidence based. However, because
standards can create stipulations that incur additional production costs and thus reduce
profitability, the business sector may seek to influence standard setting. For example,
Bero (2003) documents how TTCs worked through the Cooperation Centre for
Scientific Research Relative to Tobacco to influence ISO standards. Industry representa-
tives dominated the ISO committees involved, supplied industry-derived data, inhibited
 Business Sector in Global Health Politics   399

participation by other actors, and developed industry-favouring testing methods.

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

promoting industry-favouring values and world views; organising or sponsoring public

events; and working through third parties (sometimes covertly) such as think tanks,
paid consultants, industry-supported advocacy groups, and prominent public figures.
For example, the Better Regulation initiative in the European Union has been widely
promoted amongst policymakers and officials by major corporations, which claim that
over regulation of industry is hindering economic prosperity. As Dow Chemical (2017)
states: ‘The number of EU health, safety and environment related regulations directly
applicable to the EU chemicals industry, has nearly doubled in the last ten years to
more than 1,700 legal acts in place today. Current studies conducted for the European
Commission suggest that there is a significant cumulative cost to industry, and a
­negative impact on international competitiveness’. Subsequently, Better Regulation
principles have come to be promoted by the European Commission (2016) itself as a
means of reducing ‘meddling in the lives of citizens or businesses with too many and
too detailed rules’. However, as Berry and Devlin (2015: 8) argue, ‘This agenda and the
institutions used to deliver ‘better regulation’ are portrayed to the public as part of a
positive process of liberation from unnecessary and frustrating red tape, disguising
the fact that they weaken and prevent effective laws for the protection of society and
the environment’.
In other words, norms are created and fostered by powerful corporate interests that
depict regulation as necessarily intrusive, over-reaching, and invariably to be reduced,
all the while serving certain business sector interests under the guise of public interest.
More fundamentally, the extent to which certain ideas, values, and norms have come to
shape global health governance lies at the heart of Gill and Benatar’s critique of the
Lancet–University of Oslo Commission Report on Global Governance for Health. They
write that the ‘analysis and suggested reforms to prevailing institutions and practises
are confined within the perspective of the dominant—although unsustainable and
inequitable—market-oriented, neoliberal development model of global capitalism’ (Gill
and Benatar 2016: 346).
As well as reducing the strength and scope of regulation, many parts of the business
sector have supported the adoption of non-binding regulatory frameworks in global
health, to be adopted and implemented voluntarily by corporate actors. Voluntary
standards can enhance company reputation and even guard against legal liability
(Fulponi 2006), while retaining discretionary power over what standards to adopt or
reject (Ollila 2005). For example, many transnational food companies have pledged to
curtail marketing targeted at children and improve food labelling, but the specific com-
mitments made have been set by the companies themselves. Moreover, these pledges
have come amid growing calls for stronger and binding government regulation (Sharma,
Teret, and Brownell 2010). The extent to which non-binding regulatory frameworks
have led to fundamental changes in corporate behaviour, which in turn may lead to
improved global health outcomes, has received limited study to date. The capacities of
the business sector to exert both material and ideational power, increasingly as partici-
pants in global health governance, requires far greater critical scrutiny.
 Business Sector in Global Health Politics   401

What Should Be the Role of

the Business Sector in
Global Health Politics?

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

from major corporations (many of which reportedly pay little or no taxes), and then its
allocation by governments for the public good, is favoured over private sector control
over donations. The aggregation of donor decisions has been shown to skew the global
health agenda towards certain needs, to the neglect of others (McCoy, Chand, and
Sridhar 2009). Data on financing for global health have improved significantly since the
1990s, enabling analyses of funding by source, channel, and health focus area. Corporate
(US$690 million) and other private (US$3.1 billion) donations for global health repre-
sented around 10 percent of total financing for global health in 2016 (Institute for Health
Metrics and Evaluation 2016). Alongside more detailed analysis of the specific channels
and health focus areas supported by the business sector, there is need for deeper under-
standing of the political strategies underpinning the business sector’s contributions to
global health.
Second, as a major contributor to global health initiatives, by extension the business
sector has come to be seen by some as a legitimate stakeholder in the governance of
these initiatives. While these governance roles have varied in power and influence, the
broad shift from rule-taker to rule-maker represents a further blurring of the public and
private spheres in global health politics. The desirability of more formalised political
authority has elicited strong opinions within the public health community. There remains
deep distrust due to efforts by the business sector to prevent or weaken public health
standards and regulations. For example, when the Global Business Coalition for Health
argued for business interests to participate in the 2011 UN High Level Meeting on the
Prevention and Control of Non-communicable Diseases, public health advocates
successfully opposed participation by companies such as Coca-Cola (Gonsalves 2011).
Revelations of research funding by Coca-Cola to downplay the role of diet in increasing
rates of obesity have solidified these concerns (O’Connor 2015). Others challenge the
appropriateness of private, for-profit actors asserting decision-making power in public
interest issues. Kanavos, Costa-Font, and Seeley (2008), for instance, warn that this may
lead to the prioritisation of issue-areas and populations offering greater market oppor-
tunities, regulatory frameworks that are market favouring rather than constraining, and
modes of operation that support rather than challenge market capitalism (Kanavos et al.
2008). This blurring of political authority held by the public and private sectors has
become a central battleground in global health politics. Scholarly analysis of the extent
to which this represents needed innovation in forms of global health governance or a
‘privatisation’ or co-option of public authority is greatly needed. The implications for
political processes and outcomes in global health require particular scrutiny.
Finally, most scholarship to date on the business sector and global health politics has
focused on the material forms of corporate power, such as increasingly important
donors and occupiers of formal decision-making roles. This is understandable given the
acute concentration of global wealth in fewer and fewer pockets. Far less is known,
however, about how business interests hold and assert discursive forms of power, which
in turn influence the norms, values, and beliefs underpinning global health politics.
This chapter has briefly described how many corporate actors have pursued their
material interests using strategies aimed at shaping public opinion and scholarly and
 Business Sector in Global Health Politics   403

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

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 chapter 21

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

Jeremy Youde

The World Health Organization (WHO), the intergovernmental organisation with a

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

Philanthropy, International
Relations, and Power

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

donations to groups, causes, or individuals. The second is outcome-based: philanthropy

seeks to use those finances to promote the welfare of others or improve the public good
(Bremner 1988, 2–3). This does not necessarily mean that philanthropy is wholly selfless;
Schuyt explains that philanthropy can be driven by anything from a sense of religious
obligation to fear (2013, 5–10). Rather, the idea is that the donor is not the primary
beneficiary of the largesse. Furthermore, philanthropy is separate from the state; it
comes from individuals, foundations, or corporations.
The academic discipline of international relations has typically shied away from
investigating the role of philanthropy because of its primary analytical focus on the
state. That is particularly unfortunate, as philanthropy has played significant roles in
shaping the practise of international relations. Andrew Carnegie donated $1.5 million in
1903 to construct the Peace Palace at The Hague to serve as the headquarters for the
Permanent Arbitration Court. Two generations of the Rockefeller family—John D. Jr
and Nelson—purchased and donated the land for the headquarters of the United
Nations (UN) in New York (Mires 2013, 214–216). More recently Ted Turner pledged
$1 billion to the UN Foundation in 1998 (Partzsch and Fuchs 2012, 360–361). These
actions have provided both permanence and necessary financing to make international
organisations possible.
The historical role of private philanthropy is pronounced in global health governance.
From 1913 to 1951 the International Health Division (IHD) of the Rockefeller Foundation
(RF) was the most important funder of cross-border health concerns. Spending between
$18 and $25 million per year for most of its existence, the IHD led campaigns to reduce
hookworm and conducted important research on malaria. More important, it provided
the financing necessary to support a large portion of the operations of the Health Office
of the League of Nations (HOLN). The IHD’s contributions were particularly important
because the League itself had few resources available for such support (Youde 2013,
143–147). In fact, the IHD funded approximately half of the HOLN’s annual budgetary
outlays (Murphy 1994, 183). Farley argues that ‘before the founding of the WHO in 1948,
it [IHD] was arguably the world’s most important agency of public health work’ (2004,
2). Private philanthropy not only made the first generation of international health
organisations possible, it also set the stage for today’s global health governance system.
When philanthropy and international relations intersect, questions of power are
raised. The financial largesse of major philanthropic donors can alter the balance and
exercise of power within the international system. Wealth could provide a donor with
power over other actors, allowing the donor to force a recipient to do something it would
not otherwise do (Dahl 1957, 201); the donor will only give a state money if that government
agrees to certain policies. Wealth could also allow a donor to exercise material
­structuralist power if the donor can limit the scope of political and institutional pro-
cesses that prevent another party from raising issues important to it (Bachrach and
Baratz 1962, 948). This same wealth could allow the donor to exercise discursive power
by ‘influencing, shaping, or determining [another’s] very wants’ (Lukes 2005, 27). In
each of these instances, the concern about philanthropy and global health (or inter-
national relations writ large) is that money gives the donor the ability to alter the political
 Philanthropy and Global Health   411

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

Philanthropy and Global

Health Today

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

estimates the BMGF’s total DAH in 2014 at $1.62 billion, making it the sixth-largest
donor for global health that year, surpassing most states (Institute for Health Metrics
and Evaluation 2015, 89). Since its inception the BMGF has provided more than
$15 billion through its global health programme, making it an increasingly relevant
player in global health politics. In addition to the BMGF, other US-based philanthropic
organisations contributed an additional $385 million in 2014, slightly more than the
global health aid provided by the Australian government in that year (Institute for
Health Metrics and Evaluation 2016, 88–89).
The BMGF’s involvement in global health began in the 1990s. In 1994 Bill Gates
established the William H. Gates Foundation with an endowment of $106 million, run
by his father on a volunteer basis. Initially it focused on issues in the Pacific Northwest of
the United States. The connection to global health emerged, according to the BMGF,
when Bill Gates read an article in the New York Times about the health consequences of
the lack of access to clean water in developing countries. Gates was so moved by this
article that he passed it along to his father with a note that read, ‘Dad, maybe we can do
something about this’ (Bill and Melinda Gates Foundation n.d.). This spurred the
William H. Gates Foundation into taking action on global health. In 1999 the Bill and
Melinda Gates Foundation came into existence through a merger of three different
philanthropies started by Bill Gates during the 1990s. By the end of that year, the BMGF
had an endowment of $17.1 billion (Funding Universe n.d.), and global health was one of
its core funding areas. The organisation received a huge financial boost in 2006 when
Warren Buffett, then the world’s wealthiest person, announced that he would give the
BMGF ten million Class B shares of Berkshire Hathaway spread out over a number of
years. With the estimated value of the shares at $30 billion, Buffett’s donation doubled
the endowment of what was already the world’s wealthiest philanthropy. In addition,
Buffett’s donation included a stipulation that the annual amount the BMGF received
through his donations had to be used to increase the organisation’s annual grant making
and not simply sit in the bank (Loomis 2006). With the BMGF receiving between
$1.25 billion and $2.15 billion from Buffett annually, this meant that the organisation has
expanded its philanthropic activity in global health tremendously.
The BMGF portrays itself as a partner for governments, providing resources and
funds that governments cannot. Gates notes that the global economic recession has
placed greater strain on national budgets, making it more difficult for traditional donor
states to maintain their foreign aid budgets. Into this gap, he notes, foundations like his
can enter (Gates 2010, 15–17). Chen notes, however, that the BMGF places restrictions
on what types of global health activities it will fund. In particular, it takes a biomedical
approach and focuses its funds on research and development of treatment for infectious
diseases. It offers little support for healthcare infrastructure, since it sees that as a
­primary responsibility of government (Chen 2006, 663).
Through its prodigious spending, the BMGF has had an important effect on the
global health agenda in three key ways. First, its willingness to devote significant
resources to global health issues has called attention to serious health challenges.
Devoting substantial money to an issue grabs international attention and helps shape
 Philanthropy and Global Health   413

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

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

Advantages of Philanthropy
in Global Health

Advocates for engaging philanthropic organisations in global health point to three

important contributions that such funding sources can make to the international
­system. First, philanthropic foundations increase the diversity of funding sources
available for global health issues. This can help to fill gaps that governments are unable
or unwilling to address. Weisbrod (1975) explains that non-profit organisations and the
voluntary sector, including philanthropic foundations, emerge to satisfy an unfulfilled
demand for a public good. In this case, governments and international organisations are
unable or unwilling to provide sufficient funding to address global health needs.
Philanthropic foundations can thus satisfy a need through a paradigm of partnership
and an informal division of labour between governmental and non-governmental
sources to supplement, rather than replace, the state (Salmon 1989, 42–44).
 Philanthropy and Global Health   415

When the Rockefeller Foundation started investing in international health programmes,

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

industry (Danzon 2007). In this way, not only can a philanthropic organisation like the
BMGF itself directly contribute to the betterment of global health, but it can also use its
resources to encourage others to become involved. Indeed, Matthews and Ho cite the
BMGF’s high-profile health activities as raising awareness of international health within
the US government and encouraging the federal government to devote more resources
to these issues (Matthews and Ho 2008, 411–412). The IHD focused its health inter-
ventions and programmes specifically on areas that did not receive attention from
governments or that governments could not address on their own. Few governments in
malarial areas in the early twentieth century had the resources to effectively combat the
disease or undertake the massive operations necessary to eliminate mosquito breeding
grounds. The yellow fever vaccine mentioned above was developed because of invest-
ment from the IHD. Whilst (RED) does not fund scientific research, its funding has
allowed the Global Fund to provide grants to increase access to antiretroviral drugs in
sub-Saharan Africa. It has also arguably increased public awareness about differential
access to antiretroviral drugs, which may encourage individuals to pressure their gov-
ernments into taking action on this front. The average consumer may not pay much
attention to HIV/AIDS in Africa, but (RED) offers an avenue through which an indi-
vidual’s awareness of the issue can be increased.
Third, private philanthropic actors can spur innovation and offer unique tools for
encouraging new approaches to advancing the global health agenda. Adding philan-
thropic actors to the global health governance mix allows for greater diversity in strat-
egies and approaches employed in order to address pressing concerns. Philanthropy can
provide the necessary risk capital to support new ventures and strategies (Moran 2011,
125). Employing this sort of philanthrocapitalism to global health aims to combine the
business acumen of the private sector with the public mobilisation necessary to achieve
large-scale social change (McCoy and McGoey 2011, 146).
The BMGF explicitly describes its approach to global health as embracing a certain
entrepreneurial logic. It uses programmes like the Grand Challenges in Global Health
to spur innovation. This programme has identified fifteen specific challenges in seven
different goal areas—such as developing a genetic strategy to deplete or incapacitate
disease-transmitting insect populations or developing needle-free vaccination
­systems—and provides a financial incentive to become involved in addressing serious
gaps in the global health research agenda (Varmus et al. 2003). Governments could
initiate this sort of action on their own, but philanthropic actors have demonstrated a
greater willingness to use these sorts of innovative techniques to increase involvement
in global health issues. The IHD’s innovation came from its willingness to engage in
international health work in a variety of countries. At a time when few governments saw
much reason to involve themselves in international health, the IHD demonstrated that
cooperation on international health was both feasible and mutually beneficial. (RED)
has sought to harness existing behaviours and mould them for public good. Rather than
trying to get consumers to change their actions, (RED) tries to take advantage of those
actions. If a person is going to buy a pair of high-end headphones, why not encourage
 Philanthropy and Global Health   417

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

Criticisms of Philanthropy’s Role

in Global Health

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

The criticisms of the BMGF’s work on malaria illustrate many of these concerns. In a
2008 memo to senior WHO officials, Arata Kochi, the head of WHO’s malaria
­programme, complained about the BMGF’s overbearing influence. He argued that it
was stifling debate about how best to treat and prevent malaria because it only prioritised
(and funded) research on new drugs and new technologies. This was particularly
problematic, Kochi wrote, because the BMGF funded so many researchers that it was
impossible to find independent and impartial reviewers for research proposals that did
not hew to the BMGF’s preferred methods. He argued that the foundation was over-
stepping its bounds by essentially taking over WHO’s policymaking functions. An
unnamed ally of Kochi went further, describing BMGF-funded groups as being ‘cowed
into stomach-churning groupthink’ (McNeil 2008).
Second, critics describe philanthropy as essentially a smokescreen designed to
obscure the failures and inequalities inherent within the current international economic
system. These philanthropies get their funding from businesses that exploit the liberal
economic order to extract wealth. In turn, they reify and justify this system by making it
seem benevolent. Donors necessarily have a high degree of power over the recipients.
The donors have a sense of agency because they can make choices about who should get
money; recipients are at the mercy of donors and may have to alter their plans to satisfy a
donor’s interests. Schervish and Ostrander call attention to this power relationship,
showing how it actually prioritizes the donor’s interests whilst appearing altruistic (1990,
70–75). As such, philanthropic organisations can use their wealth to maintain the
status quo, punish potential challengers, and whitewash the problems in the current
economic order.
For example, critics argue that upon its creation in 1913, the IHD’s activities ‘were
directed more generally at improving the health of each country’s work force to facilitate
sufficient economic development to provide the United States with needed raw materials
and an adequate market for this country’s manufactured goods’ (Brown 1979, 116). They
took this as evidence that Rockefeller’s true interest was enriching himself and using his
seeming humanitarian work as a ruse to distract attention or criticism. Other critics
allowed that honest altruism played some role in guiding the IHD’s operations, but they
argued that this was secondary to its genuine interest in transforming parts of the world
to be more economically and politically receptive to US business interests (Löwy and
Zylberman 2000, 368). Brown describes the IHD’s programmes as ‘explicitly intended to
develop and strengthen institutions that would extend the reach and tighten the grasp of
capitalism throughout the society’ (1979, 8–9). In addition to promoting US interests,
critics charged that the IHD specifically aimed to prevent the emergence of radical and/
or labour movements that would question the very political and economic systems that
gave the Rockefeller Foundation its wealth in the first place. If the IHD could provide
health programmes, people would be less inclined to acknowledge the miseries caused
by capitalism and thus less interested in joining labour or socialist organisations
(Brown 1979, 116–119).
Similar charges have dogged the BMGF throughout its existence. Rather than
challenging the status quo, critics argue that the BMGF takes the wealth that it
 Philanthropy and Global Health   419

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

tends to favour exhibit a similar technological bias. Rather than trying to improve access
to existing worthwhile technologies, it seeks to create new drugs and technologies
(McNeil 2008). As a result, its emphasis promotes approaches that could bring financial
remuneration down the road. For example, the BMGF’s own antimalarial programmes
promote developing new drugs, new vaccines, and new technologies that may be
inappropriate or unworkable in many settings. This has the effect of ‘creat[ing] short-
sighted agendas that may miss the most pressing health problems’ (Barth 2010). The
foundation’s technological biases mean that it is unable to genuinely address the
health concerns that it proclaims it wants to address and improve.
Finally, critics allege that few measures of public accountability can exist to provide
any sort of oversight of philanthropic organisations. Philanthropists exert significant
public policy influence, yet the public itself is largely absent from the conversation. It
replaces a mass democratic voice in intergovernmental organisations with a top-down
autocratic one that is answerable to no outside or public actor. There is no opportunity
for a public dialogue about the priorities and strategies of philanthropic organisations.
The Rockefeller Foundation and BMGF both have trustees, but theirs is a fiduciary
responsibility to the organisation. The trustees, and by extension the philanthropic
organisations that they oversee, are without any sort of broad-based legitimacy due to
the lack of any mass deliberative process or public involvement.
From its beginning, the IHD (and the Rockefeller Foundation as a whole) came under
intense scrutiny about the legitimacy of its operations. The organisation raised suspi-
cions in some quarters that it was ultimately an instrument of American imperialism
that operated outside the boundaries of normal democratic control. These concerns
nearly prevented the Rockefeller Foundation from beginning operations in the first
place. Between 1910 and 1912 John D. Rockefeller repeatedly sought to gain a federal
charter from Congress for his philanthropic organisation. On each occasion, Congress
rejected his application because of its concerns about his business practises, describing
the organisation as holding ‘tainted money’ and symbolic of a ‘creeping capitalism’ that
exploited the poor. Since Congress saw Rockefeller’s wealth as ill-gotten and lacked the
ability to regulate his business operations at that time, it did not want to give him another
unregulated realm in which he could operate. After his repeated failures at the federal
level, the Rockefeller Foundation eventually received a charter from New York State in
1913 and began its operations (Cunningim 1972, 20). That did not silence the founda-
tion’s critics, however; they continued to deride the organisation for lacking any
accountability to the people it presumably served (Palmer 2009, 681).
The BMGF faces similar charges of being both unaccountable and undemocratic. An
editorial in The Lancet in 2009 questioned how the BMGF set its priorities, arguing that
it lacked an overall global health strategy and was instead driven by the idiosyncratic
interests of its founders. ‘For such a large and influential investor in global health, is such
a whimsical governance principle good enough?’ it asked (The Lancet 2009, 1577).
Others take the BMGF to task for its narrow range of grantees and funding priorities.
McCoy et al. (2009b) found that organisations and universities based in the United
States received 82 percent of the grant monies that went to nationally based recipients
 Philanthropy and Global Health   421

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

Conclusion

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

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

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 chapter 22

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

Chris Holden and Benjamin Hawkins

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

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

The World Trade Organization

and the Global Politics of Health

The WTO was established in 1995, following the Uruguay Round of trade negotiations.
It is the successor to the multilateral trade system centred on the General Agreement on
Tariffs and Trade (GATT), which governed international trade during the post–World
War II period. The GATT system, and the WTO system that succeeded it, operates on
the basis of periodic ‘rounds’ of trade negotiations by member states, which negotiate
with each other to bargain down tariff rates and other trade barriers. The Uruguay
Round agreed to create the WTO and added to the GATT a series of new trade agree­
ments, including the General Agreement on Trade in Services (GATS), the Agreement
on Trade-Related Aspects of Intellectual Property Rights (TRIPS), the Agreement on
the Application of Sanitary and Phytosanitary Measures (the SPS Agreement, concerned
with regulations to protect human, animal, and plant life and health), and the Technical
Barriers to Trade (TBT) Agreement.
 Trade and Investment Agreements   429

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

Indonesia versus the United States on Cigarette Flavourings

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

candy, fruit, clove, and cinnamon, but exempted menthol. The intent was to protect
youth and children from smoking, since it was believed that they are more likely to be
attracted to flavoured cigarettes.
In June 2010 Indonesia requested the establishment of a WTO dispute panel, arguing
that the banning of clove cigarettes was discriminatory, given that menthol cigarettes
had been exempted. Indonesia is the world’s fifth largest cigarette market, with the
tobacco industry exerting a high level of influence on government policy (Hurt et al.
2012, 306). Clove cigarettes (known as ‘kreteks’) are the main form of tobacco consump­
tion in Indonesia. The country is the largest exporter of such cigarettes to the United
States and other countries. While the clove cigarette market is small in the United States,
most clove cigarettes are imported, whereas most menthol cigarettes are produced
domestically (Jarman 2015, 64). Menthol is the most popular flavoured cigarette in the
United States, with a large market amongst African Americans. The Indonesian govern­
ment argued that the differential treatment of clove and menthol cigarettes, which
should be regarded as like products, was discriminatory and therefore violated both the
GATT and the TBT agreements, and further that the US measure was more trade
restrictive than necessary to protect human health (WTO 2014).
The WTO dispute panel concluded in September 2011 that the US law violated WTO
law by treating like products differently, although it rejected Indonesia’s claim that the
US measure was more trade restrictive than necessary. The United States then appealed,
and the Appellate Body upheld the panel’s original ruling, although with some minor
differences in the interpretation of the relevant agreements (see McGrady and Jones 2013
for a full legal analysis). Given that the banning of clove cigarettes, alongside the con­
tinuing allowance of the sale of menthol cigarettes, constituted discrimination between
like products under WTO law, the US government faced the choice of whether to bring
its laws into conformity with WTO law, by allowing the sale of clove cigarettes or ban­
ning the sale of menthol cigarettes, or to refuse to do so and face sanctions.
The manner in which the dispute was ultimately resolved tells us as much about the
global politics of trade and health as it does about the formal legal processes within the
WTO. First, the US government had to consider the domestic implications of banning
menthol cigarettes. Both scientific and political considerations were relevant. In terms of
the scientific evidence on the effects of menthol in masking the harshness of tobacco, the
United States argued in the dispute that clove cigarettes were more attractive to young
people and therefore posed a greater health risk than menthol cigarettes. However, the
panel and the Appellate Body ruled that menthol and clove cigarettes had the same char­
acteristics in terms of their effect on rates of youth smoking (McGrady and Jones 2013).
The United States also argued that it was legitimate to exempt menthol cigarettes from
the ban because to include them might lead to a large number of citizens experiencing
sudden withdrawal from nicotine addiction and a large rise in illicit trade. Both claims
were rejected by the Appellate Body, since ordinary cigarettes would still be available
(McCabe Centre for Law and Cancer 2014).
When first passing the Act, the US government had in fact postponed a decision on
whether to ban menthol cigarettes, instead asking the FDA’s Tobacco Products Scientific
 Trade and Investment Agreements   431

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

It has been observed that President Barack Obama may have been reluctant to engage in
another political battle while embroiled in defending his healthcare reforms and negoti­
ating over the federal deficit (Zajac 2011; Siegel 2011). Furthermore, the tobacco control
community was split on the issue of exempting menthol, since this was the result of
an uneasy compromise between the industry and some tobacco control advocates
(Siegel 2011). Tobacco control advocates supporting this compromise argued that it was
a necessary trade-off to ensure the industry conceded the FDA’s authority to regulate
tobacco products, which the industry had previously been successful in legally challen­
ging (Jarman 2015, 64). However, the divisions amongst public health advocates on this
issue allowed the tobacco industry to dominate the public discourse, claiming that a ban
on menthol cigarettes would lead to an increase in illicit trade (Cheyne et al. 2014).
A WTO ruling in a case such as this would normally lead to a change in national-level
law or relevant regulations to bring them into compliance. In this case, this would have
meant the US government either banning menthol cigarettes or allowing the sale of
clove cigarettes. However, the evidence in favour of a ban on flavoured cigarettes in gen­
eral, including clove, had already been accepted by the US government when it passed
the Act and had also been accepted by the WTO panel and Appellate Body as legitimate
(as long as it was undertaken in a non-discriminatory manner). Thus, amending the Act
to allow the sale of clove cigarettes was not a satisfactory solution. The domestic political
obstacles to US compliance, therefore, led the United States to take measures short of
banning menthol, including releasing the FDA’s scientific evaluation of menthol cigar­
ettes, developing a youth education campaign, providing information on the health
risks posed by menthol cigarettes through a website, and educating the public through
the National Cancer Institute website (McCabe Centre for Law and Cancer 2014). When
a complaining member state believes a defending state has not complied with a WTO
disputes ruling, the affected state can apply for the right to suspend concessions (i.e.,
implement sanctions), as Indonesia then did. When the United States objected, the
matter was referred to WTO arbitration. However, before an arbitration decision was
returned, the two governments announced a memorandum of understanding and the
WTO process then ceased.
Under the negotiated settlement, the US Act remained in force, but the US government
agreed not to impede market access by Indonesian clove cigars and cigarillos, at least
until new non-discriminatory measures could be introduced (ICTSD 2014; McCabe
Centre for Law and Cancer 2014). This was in the context of Indonesian clove cigarette
manufacturers having adapted clove cigarettes into cigars and cigarillos to circumvent
the ban. The settlement also involved a number of trade-related matters not directly
connected to the clove cigarettes dispute. These included a commitment by the United
States that it would not submit a WTO challenge regarding unrelated mineral export
restrictions imposed by Indonesia; a commitment by the United States to grant add­
itional ‘facilities’ to Indonesia should Congress reauthorize the Generalized System of
Preferences, a trade program to support less-developed countries; and an agreement
that the two countries would intensify negotiations to strengthen intellectual property
rights in Indonesia (ICTSD 2014; Needham 2014). They also agreed to intensify their
 Trade and Investment Agreements   433

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

Other WTO Disputes and the Global Politics of Health

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

many cases with LMICs as the complainants, despite their relative lack of legal capacity.
In such cases, these governments may act as surrogates for TTCs, which have been
marginalised from the policymaking process in many HICs (Eckhardt et al 2016).
A particularly important example is the WTO disputes initiated by Ukraine (later
withdrawn), Honduras, Dominican Republic, Cuba, and Indonesia against Australia’s
introduction of plain packaging, claiming intellectual property rights violations, with
Philip Morris International (PMI) and British American Tobacco (BAT) paying the
legal expenses of some of the complainant countries (Eckhardt et al. 2016). Lobbying
and various forms of assistance or inducement may therefore lead to WTO member
states acting as proxies for corporate interests, with a shift from HICs to LMICs as the
complainants (Eckhardt and De Bievre 2015).
WTO agreements also have implications for the politics of other major health issues.
For example, the TRIPS Agreement may impact the affordability of medicines in LMICs
(Smith et al. 2009). GATS has potentially far-reaching consequences for the delivery of
health services, primarily because it raises questions about the extent to which govern­
ments can protect state-provided or -financed services from commercial competition
(Holden 2014). While there has not yet been a significant GATS dispute relating to
health services, there have been important WTO disputes in other areas relating to
health. For example, the United States and Canada initiated a dispute against the
European Union (EU) in 1996 to challenge the latter’s imposition of a ban on the import
of hormone-treated beef (WTO 2016). While the case is extremely complex, the panel
found in favour of the United States and Canada on the basis that there was not sufficient
evidence of the harmfulness of the hormones. The dispute is of particular relevance
because it casts doubt on the extent to which WTO panels will take account of the ‘pre­
cautionary principle’, which states that in the absence of scientific consensus, the burden
of proof that something is not harmful rests with those taking the relevant action (in this
case, using certain hormones in the rearing of beef). The WTO agreement dealing most
explicitly with food standards, the SPS agreement, allows governments to put in place
provisional measures to protect health where scientific evidence is inconclusive, but
these must be temporary while further information is sought to clarify the risk (WHO/
WTO 2002, 67–68). In another example, Canada filed a complaint against France in
1998, arguing that France’s imposition of a ban on chrysotile asbestos treated imported
asbestos less favourably than domestic asbestos substitutes. In this case, the WTO
Appellate Body ruled in France’s favour on the basis that the ban was a legitimate meas­
ure to protect health (WTO 2010; WHO/WTO 2002).
It is not only WTO agreements that are significant for health. In recent decades
numerous bilateral and regional trade and investment agreements have emerged that
have potentially wide-ranging health impacts. A key feature of the WTO system is
that it is premised on bargaining between states, which have de jure equivalence, des­
pite their de facto differences in terms of their economic and political power. This
interstate bargaining has led to deadlock in the most recent WTO negotiating round,
the Doha Round. China’s increased weight in the global economy, and its membership
 Trade and Investment Agreements   435

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

Conflicts over ‘Next Generation’

Trade and Investment Agreements

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

trade of manufactured goods between advanced economies have fallen to historically

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

Investor-State Dispute Settlement, Corporate Interests,

and Health
ISDS mechanisms have existed for some time within bilateral investment treaties (BITs)
dating back to the Germany-Pakistan BIT in 1959. The number of BITs expanded hugely
during and after the 1990s, with over 2,500 now in existence. However, the principle of
ISDS became increasingly controversial following its proposed incorporation within
TPP, TTIP, and CETA. ISDS mechanisms seek to reassure transnational investors—
predominantly TNCs—that their investments will be safe from arbitrary expropriation,
and that they will be subject to ‘fair and equitable treatment’ and thus allow investors to
initiate disputes directly with governments where such guarantees appear to have been
violated (McGrady 2012). ISDS mechanisms were introduced initially in BITs between
high-income and low-income countries, as an antidote to concerns about the effective­
ness of legal systems in LMICs receiving investment and the ability of investors to fully
guarantee their property rights within existing legal structures. The proposed inclusion
of ISDS provisions within TTIP—an agreement between two advanced capitalist
economies with highly developed independent legal systems—has proved particularly
controversial. Civil society movements across the relevant countries have mobilised
against all three agreements, and subsequent opposition by some leading politicians and
major political parties has meant that the passage of the agreements through the rele­
vant parliaments is far from guaranteed, as explained below.
ISDS has been particularly controversial because of the direct, and exclusive, rights it
gives to corporations to initiate disputes with governments. While in the WTO system
corporations can lobby member states to initiate disputes on their behalf, under ISDS
mechanisms corporations have legal standing to initiate disputes directly with ‘host’
governments. ISDS mechanisms are also not overseen by a multilateral body such as the
 Trade and Investment Agreements   437

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

Regulatory Cooperation and Health

As discussed in the previous section, ISDS measures introduce a mechanism through
which investors can seek ex post remedies to unfair or discriminatory practises that
contravene the principles of trade and investment agreements. Both TPP and TTIP,
however, proposed moving beyond this to include more robust ex ante mechanisms to
ensure national laws remain in accordance with a state’s obligations under the agree­
ment. While TPP includes a chapter on ‘regulatory coherence’, the draft TTIP agreement
includes chapters on both regulatory coherence and ‘regulatory cooperation’. The latter
is designed as a form of monitoring and oversight of proposed domestic legislation
before its adoption. However, since the TTIP agreement remains under negotiation, the
precise details of how this would function in practise, the institutional structures that
would oversee and administer it, and the degree of access this would afford to private
stakeholders such as TNCs remain uncertain. This section focuses principally on TTIP,
as the most far-reaching set of proposals in this area, but many of the concerns raised
here are pertinent to discussions about the impact of other agreements such as TPP.
The process of negotiation at an interregional level for TTIP is analogous to that
undertaken within the EU during the completion of the single internal market (SIM)
(see Egan 2001). In order to create a genuinely European market, the European
Commission sought to harmonise production and safety standards in specific areas to
create common benchmarks, which all producers must adhere to regardless of national
origin. In other areas, where harmonisation was deemed unnecessary or impractical,
the norm of mutual recognition was established, whereby products legally produced
and deemed safe to bring to market in any member state must be accepted within other
EU states. Like the SIM project, TTIP necessitates the formulation of either common
standards (harmonisation), on issues such as food safety and a range of other issues, or
mutual recognition of standards between the United States and the EU. Regulatory
cooperation mechanisms are designed to ensure that proposed laws do not undermine
either regime. If ISDS is a mechanism of redress, in cases in which the fundamental
principles of the agreement are seen to have been infringed by government acts, regula­
tory cooperation is designed to avoid such instances occurring in the first place.
Critics of TTIP have highlighted the importance of the Regulatory Cooperation
Chapter within the agreement on similar grounds to ISDS mechanisms. The establish­
ment of processes and structures that would require draft laws on both sides of the
Atlantic to be scrutinised prior to their adoption, and perhaps even to their formal pro­
posal, has clear implications for democratic accountability and legislative sovereignty. It
affords corporate actors a potentially powerful mechanism through which to influence
policy at the pre-proposal stages of the legislative process. The ability to set agendas and
shape legislation at the very earliest juncture has long been identified as a key aspect of
the exercise of political power (Bachrach and Baratz 1962). Similarly, scholars of behav­
ioural economics have long understood the importance of initial proposals in ‘anchoring’
subsequent negotiations (Tversky and Kahneman 1974). This has fuelled concerns that,
 Trade and Investment Agreements   439

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

Political Struggles over the New Agreements

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

agreements, including those related to alcoholic drinks and processed foods (Hawkins
and Holden 2016).
In the TTIP negotiations, the ISDS provisions became so controversial that the
European Commission proposed replacing ad hoc adjudication panels with a perman­
ent investment court system (ICS). This idea has now been incorporated within CETA.
Similarly, initial proposals for a highly institutionalised form of regulatory cooperation,
through the creation of a regulatory cooperation council, were watered down in draft
texts of the agreement released by the European Commission in March 2016. These were
replaced by vaguer commitments to create regulatory cooperation mechanisms, which
may be less formalised but will also be less transparent and equally able to shape policy
debates. Delaying agreement on the precise form of the mechanism until after the agree­
ment is finalised grants far-reaching delegated powers to the European Commission
and the US government to put in place practises with significant democratic conse­
quences, without the degree of scrutiny to which they are subjected during formal trade
negotiations and ratification procedures.
The processes of ratification of trade and investment agreements allow us to see the
importance of domestic political institutions for the success or failure of such agree­
ments. National parliaments, as well as the European Parliament, have an important
role in deciding whether agreements are ratified and can therefore exert influence over
the contents of those agreements, even where they cannot directly amend them. In the
United States, Congress is required to ratify such agreements, but ‘fast track’ or ‘trade
promotion’ authority has usually been granted to the president, under which Congress’s
power is limited to passing or rejecting the treaty text as a whole, without the ability to
make detailed amendments to its provisions.
In the EU, where an agreement is designated as a ‘mixed’ agreement, that is, an agree­
ment that includes areas of national as well as EU competence, agreements must be ratified
not just by the European Parliament but also by national governments in accordance
with their own constitutional requirements. This requires the agreement of twenty-eight
national and ten regional parliaments. In the case of CETA, the signing of the agreement
was delayed due to the opposition of the Walloonian regional government in Belgium.
A last-minute round of shuttle diplomacy amongst Canada, the EU member states, and
regional administrations led to the addition of supplementary protocols to the agreement
to provide the Walloonian Assembly with further guarantees of its right to regulate in
the public interest and its ability to guarantee strong labour market, environmental, and
consumer standards. The agreement was signed in a rearranged ceremony on October
30, 2016, two days later than planned. At the time of writing, the ratification process was
yet to be completed.
National governments must also take account of public opinion on agreements when
seeking re-election, with TTIP becoming a key political issue in many EU member
states. In the United States, both TTIP and TPP, as well as the existing North American
Free Trade Agreement (NAFTA) amongst the United States, Canada, and Mexico, were
key issues in the 2016 presidential election, with Donald Trump stating that he would
withdraw the United States from TPP upon entering office and seek to renegotiate
 Trade and Investment Agreements   441

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

Conclusion

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

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 chapter 23

The Gl oba l Politics

of Hea lthca r e
R efor m
Solomon Benatar, David Sanders,
and Stephen Gill

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

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

The Context for Contemporary

Debates

Prior to the twentieth century, health and illness were largely interpreted through a
­minimalist understanding of the structure and function of the human body/person.
Healthcare was almost entirely dependent on diagnosis through clinical interpretation
 Global Politics of Healthcare Reform   447

of described symptoms and observed signs, supported by only simple confirmatory

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

to healthcare should be free at the point of entry, with rationing determined by ethical
considerations of clinical priority. The underlying idea was equitable access to effective
promotion of health and provision of healthcare, given constrained resources and
competing priorities, through taxation (National Insurance) and top-up payments to
avoid reducing the healthcare system to a poor-quality core.
This was a modified form of socialism, underpinned by Keynesian economics and
very progressive taxation. For example, in the United Kingdom high-income earners
were taxed at 90 percent of their earnings beyond a certain threshold. Although it is easy
to romanticise this period, in key respects it formed the framework for post-war public
policies underpinned by a spirit of solidarity and shared destiny with fellow citizens. In
addition to universal healthcare and progressive taxation (both of incomes and capital
gains), this economic agenda also raised the necessary resources for investment in
infrastructure for education, transportation, and other components of the welfare state.
This was therefore the beginning of an era of great hope for a majority of people,
particularly in the more affluent regions—in Europe and later throughout much of the
world—that the application of scientific and medical advances to everyday healthcare
would be the route to long and healthy lives for all. Evidence suggests that over the next
three decades much was achieved through these ideals and the development of socially
supportive structures. It must be emphasised, however, that these structures were
limited to a small proportion of the world’s population, principally located in
OECD countries.
By the 1970s two periods of deep economic crisis created fiscal pressures on govern-
ments worldwide, notably in low- and middle-income countries (LMICs), whose fiscal
capabilities became severely stretched (Reuss 2009; Macalister 2011). These countries
were then required to borrow from abroad, in the form of loans that came with
­conditions that required them to implement certain economic reforms. For example,
the World Bank deemed these measures forms of necessary ‘structural adjustment’ in
exchange for continued debt relief.
The political context for this shift was that policymakers increasingly sought to return
to market solutions to address economic, social, and health problems. In so doing they
claimed, as did UK prime minister Margaret Thatcher, that there was ‘no alternative’ to
neo-liberalism. She and other conservative leaders began to repudiate the post-war
settlement and the solidaristic Keynesian political economy that went with it. She made
it clear that she thought there was ‘no such thing as society’, only a collection of posses-
sive individuals who would be governed by market forces and an entrepreneurial
ethos that did not restrain operations of capitalist firms through progressive taxation.
This neo-liberal political perspective was vehemently opposed to socialism and,
according to Thatcher, was intended to ensure its eradication and to set the scene for
increased contestation between opposing perspectives on the development of healthcare
services and financing, which played out in policy reforms over the next several decades.
For example, cutting taxes for the wealthy and corporations made it more difficult to
fund expensive socialised healthcare systems without raising taxes from the poorer
 Global Politics of Healthcare Reform   449

members of the community. It is in this context that we locate healthcare reforms of the
past four decades.

Primary Healthcare: Social Solidarity

and Social Goods

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

How Alma-Ata and PHC gained the attention of the world’s health leadership has been
described as one of the most intriguing narratives in the history of health and develop-
ment (Bryant and Richmond 2008).3
By the early 1980s, however, support for a comprehensive PHCA was deemed by
some—particularly economists wedded to the neo-liberal perspective as well as sundry
conservative political leaders—to be ‘too ambitious’ (Walsh and Warren 1979) and not
feasible given the fiscal turmoil in the world economy. In a period of increasing
depoliticisation, by which core and fundamental political principles were subjected to
technocratic vocabularies and discourse, the so-called comprehensive PHC began to be
supplanted by what became known as selective PHC. This entailed the adoption in
LMICs of selected vertical health interventions, such as growth monitoring, oral
rehydration therapy (ORT), breastfeeding, and immunisation (GOBI). This selective
approach became the centrepiece of UNICEF’s Child Survival Revolution, characterised
as the ‘leading edge’ of PHC, to be followed by a more comprehensive approach at a
later stage (UNICEF 1983, 1990, 2016). The Task Force on Child Survival and
Development, supported by donors such as the US Agency for International
Development (USAID), was based on the same focus on taking forward a core
­package of priority interventions.
The shift of emphasis, away from principles of equity as a core value of social and
­economic development (along with inter-sectoral collaboration, community participation,
and sustainability) and towards market efficiency, alongside narrow definitions of
cost-effectiveness and other technocratic economic criteria, was part of a broader
ideological shift towards political conservativism beginning in the 1980s (Rifkin and
Walt 1986). This was coupled with a series of measures to take fundamental questions of
politics and the political economy out of mainstream contestation over health policies.
The belt-tightening, state-shrinking policies of neo-liberalism, prompted by problems
in the world economy such as the oil crisis, rising debt, and rapid inflation, were pre-
sented to the public by governments and donor agencies as a form of ‘common-sense’
alternative to what was deemed to be bloated and inefficient state sectors. By common
sense, we mean it was presented as self-evident that state-directed health systems
were part of the problem rather than the solution. Neo-liberals took the offensive,
backed by well-funded think tanks and against left-wing forces in many parts of the
world—now bereft of an alternative geopolitical model as previously provided by the
Soviet bloc—that were incapable of providing alternative solutions or an adequate
defence of existing systems.
Neo-liberal ideas and associated health reforms were strongly promoted by the World
Bank, beginning with the 1993 World Development Report: Investing in Health (World
Bank 1993). In promoting a more elaborate version of the selective PHC approach, in
part, the report was a response to criticisms of the World Bank’s structural adjustment
programmes. Yet rather than challenge the neo-liberal assumptions underpinning
structural adjustment, the World Bank embedded them deeper in health sector reforms
across the developing world. Since then its argument has tended to be the same, attrib-
uting every crisis or policy failure mainly to market-based reforms not having gone far
 Global Politics of Healthcare Reform   451

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

and into adult life (Evans et al 1994). Such policies fail to recognise that improvements in
health are crucially dependent on enhanced living and working conditions (Sullivan
and Adler 1999).
Finally, with healthcare being viewed as a commodity and as a source of maximisa-
tion of profit or minimisation of cost—either because of privatisation or because of the
use of a narrow form of accounting to assess health service activity—these increasingly
dominant approaches mean that the functions of community mobilisation, inter-
sectoral action, and advocacy are unlikely to be rewarded or encouraged by the broader
health system. In LMICs, narrowly ‘vertical’ (disease-focused and defined) health
programmes became more prevalent. Most donor funding for health in LMICs up to the
early 1990s was consequently provided in two ways: from the World Bank in the form of
loans and credits and through earmarked support to LMICs from bilateral donors for
vertical projects or programmes.
A centrepiece of neo-liberal restructuring over the past fifteen years has been the
dramatic growth of global health partnerships (GHPs) or global health initiatives
(GHIs) as a new mechanism for channelling donor funds to LMICs. We argue that this
new form of funding, in keeping with neo-liberal ideology, promotes private sector
involvement in the reshaping of the provision of public goods. In the health sector, this
is often in the form of ‘public-private partnerships’ (PPPs) associated with a veritable
alphabet soup of new acronyms. These include the Global Alliance on Vaccines and
Immunizations (GAVI); the Global Fund to Fight AIDS, TB and Malaria (GFATM); the
World Bank Multi-country AIDS Program (MAP); and the US President’s Emergency
Plan for AIDS Relief (PEPFAR). All are endowed with massive budgets and have become
the major sources of health financing in the world’s poorest countries, especially for
HIV, tuberculosis, and malaria (Sanders et al. 2011). Although their advent has resulted
in an exponential increase in funding for certain health (especially HIV/AIDS) pro-
grammes, it is important to recognise that they have also reinforced the selective
approach to PHC through countrywide, disease-specific funding mechanisms. Such
programmes are usually vertically implemented and managed, and they privilege
therapeutic interventions and (in selected cases) personal prevention, with little funding
for promotive interventions to address ‘upstream’ determinants such as gender inequity,
community mobilisation, or care.
Beyond donors to health development assistance, the commercialisation and privat-
isation of healthcare services during this period were supported by the governments of
wealthy countries and promoted through the General Agreement on Trade and Services
(GATS) and many bilateral free trade agreements. In effect, these are agreements that
re-regulate the provision of health and other social services and public goods by means
of liberalisation—that is, opening them up to privatisation and private investment.
Moreover, the inclusion of the Agreement on Trade-Related Aspects of Intellectual
Property Rights (TRIPS) in the World Trade Organization (WTO) has forced countries
to accept that knowledge and innovation are commodities to be bought and sold on the
world market and therefore to adopt uniform standards of intellectual property
 Global Politics of Healthcare Reform   453

­ rotection, irrespective of their stage of industrial and economic development. (Kapczynski

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

The Influence of the World Bank

and the Washington Consensus:
A Preliminary Balance Sheet

The political attitudes behind the erosion of support for universal health coverage began
when the World Bank’s 1981 Berg Report inspired industrial insurance schemes, user fees
at public health clinics, liberalisation of the pharmaceutical trade, and outsourcing of
some public health activities—all early hallmarks of neo-liberal restructuring. The 1993
World Development Report (World Bank 1993) further endorsed the neo-liberal
approach to health and introduced the term ‘disability adjusted life years’ (DALYs) as a
new measurement of the burden of disease, influenced significantly by the consideration
of losses to economic productivity. The neo-liberal reforms inspired by this approach
aggravated health inequities, and the vulnerable poor suffered more than any other
group (Rowden 2009).
The initially narrow range of economic restrictions placed on low-income countries
expanded into a broader package of overlapping policies within what came to be called
the Washington Consensus, with its development strategies focused on privatisation,
liberalisation, and macro-stability (largely price stability) policies, grounded in a strong
faith in unrestricted markets and aimed at reducing the role of government, or more
precisely restructuring the role of government so that it became market enabling and
more limited in its ability to expropriate or nationalise corporations or private health-
care producers. The ‘standard’ reform package (promoted as ‘structural adjustment’ for
indebted countries by Washington-based institutions, as described above) comprised
ten steps: fiscal discipline, public expenditure priorities, tax reform, financial liberal-
isation, unified exchange rates, trade liberalisation, foreign direct investment, privatisa-
tion, deregulation, and full protection for an extension of private property rights
(Rowden 2009).
By 1984, negative impacts of implementing structural adjustment were already evi-
dent in the health of children in many LMICs. Whilst life expectancy at birth world-
wide improved, from 46.5 years to 65.2 years between 1955 and 2002, life expectancy
fell in sub-Saharan Africa from 50 to 46 years (WHO 2003). Although the declines in
certain parts of Africa were largely due to HIV/AIDS (and to some extent have been
reversed with ARV treatments [Mayosi & Benatar 2014]), they were also in part due to
neo-liberal policy reforms, which coincided with the emergence and spread of HIV
(Rowden 2009). By the 2000s per capita incomes in forty-five developing countries
were lower than they were twenty-five years earlier. In 2003 the United Nation
Development Programme’s annual Human Development Report showed falling growth
rates in many developing countries, and the impacts of such policies on development
have been well summarised (Rowden 2009). The UNICEF Annual Report 1987:
Adjustment with a Human Face (UNICEF 1987) concluded that the main effects of the
 Global Politics of Healthcare Reform   455

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

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

Healthcare Reform since the Global

Financial Crisis: Missing in Action?

In 2008 all WHO regions reaffirmed commitment to the policy of PHC, giving WHO
the mandate to build upon its principles. The 2008 World Health Report focused on PHC
and explicitly acknowledged the previously affirmed centrality to PHC of the social
determinants of health (Werner and Sanders 1997). However, in contrast to the found-
ing declaration, it did not interrogate the global economic dispensation or call for a new
international economic order (NIEO) as proposed during the 1970s by the ‘non-aligned
movement’ to replace the Bretton Woods system. Whilst the latter had benefited the
leading states that had created it, the NIEO would favour LMICs by promoting their
interests through improved terms of trade, increased development assistance, and
reductions in developed-country tariffs. Although PHC has been adopted as a global
strategy since the 1970s, it has been more enthusiastically embraced by LMICs.
 Global Politics of Healthcare Reform   457

Inequality, Austerity, and Erosion of Professionalism

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

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

Population and Public Health

Despite all the medical and healthcare progress being made, by the end of the twentieth
century patterns of disease and of longevity still differ markedly across the world. Whilst
life expectancy at birth has continued to increase worldwide, it still ranges from well
over seventy years in highly industrialised countries to below fifty years in some poor
countries. In several sub-Saharan African countries, gains in longevity achieved during
the first half of the twentieth century were rapidly reversed by the HIV/AIDS pandemic,
although longevity is improving with the introduction of antiretroviral therapy (ART)
(Mayosi and Benatar 2014).
The emergence and spread of infectious diseases like Avian flu, HIV, SARS, MERS,
Ebola, and more recently Zika have become new focal points of popular concern about
global health. Not surprisingly, these infections tend to arise in the poorest countries,
where intimate and undesirably close interactions between humans and animals, often
the result of widespread ecological changes wrought by extractive industries that
penetrate previously uninhabited areas, facilitate the spread of infective agents from
animals to humans. These epidemics are not disconnected events and cannot be viewed
superficially as isolated biomedical crises arising from transmission of an animal virus
to humans, to be dealt with only through emergency medical rescue processes. They are
instead milestones along the pathway of complex human behavioural interactions with
nature over millennia (Garrett 1994; McMichael 2014; Boyden 2004; Benatar 2005a;
Shah 2015; Hotez and Pelperl 2015). Such infections cause most problems locally, as
­living conditions are conducive to their spread, and public health systems/measures to
prevent it are very poorly developed. These diseases can spread rapidly across the whole
world, with the potential to kill millions, given the ease and extent of travel in a
­globalised world and the many pockets of severe poverty even within the G20 countries
(Hotez and Pelperl 2015).
The post-2007 global financial crises and the 2014 Ebola epidemic in West Africa
highlighted inadequacies in global health awareness, the weakness of health systems,
the failure generally of epidemic preparedness, and the failure specifically to develop
 Global Politics of Healthcare Reform   459

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

Neglect of the Social Determinants of Health

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

Universal Access to Healthcare

Recent insights regarding the shortcomings of neo-liberal policies have prompted
renewed interest in universal access to healthcare and the need to build and support
resilient public health systems. Today UHC is being strongly promoted as a panacea for
health inequities and is manifesting in various jurisdictions as voluntary insurance
schemes, autonomous programs for the poor only, and parallel private insurance or
copayments for services beyond a basic package (Cotlear et al. 2015).
Long advocated by WHO, UHC is again being described as a major global political
goal and ethical endeavour (Chapman 2016; Reis 2016). However, as stated previously,
proposed mechanisms to achieve UHC differ widely, with tax-funded and solidarity
based initiatives constituting the minority. Reis cites the Ebola virus outbreak of
2014–2015 as a clear demonstration of the need for national, as well as international,
support for failing health systems. Solidarity and good governance within countries,
alongside international solidarity, are being identified as central requirements, together
with fair priority-setting mechanisms and engagement of people/communities in the
process of allocating resources.
These are admirable aspirations (O’Connell, Rasanathan, and Chopra 2014; Reich
et al. 2015; Sengupta 2013), but UHC must be seen in the broader context of a world in
which 70 percent of people (about five billion) live on less than US$10 per day (including
one billion people on less than US$2/day and a further four billion people on US$2–10/
day), and in which WHO has failed to demonstrate good governance of health nation-
ally and globally (Smith and Upshur 2015; Gill and Benatar 2015). Serious shortcom-
ings in the way healthcare is provided and funded in many high-income countries
(Rosenthal 2017) do not inspire confidence in the recommendations being made to
LMICs. The problem of access to affordable healthcare in India, for example, illustrates
the magnitude and complexity of the problem and failure to consider the crucial role of
the social and societal determinants of health (Barik and Thorat 2015). In this context,
the central responses to challenges are currently focused on generating resources to
cover costs, deciding how health services should be delivered (through equitable, hori-
zontally arranged healthcare systems or through parallel vertical programs), and how
healthcare professionals should be remunerated.
Politically driven disjunction between economic growth and associated advances in
science, technology, and medical care and the ability to use these to improve health
more equitably, within countries and more widely, has also reshaped the practise of
medicine (and indeed the role and image of health professionals) and the extent to
which ‘healthy’ life can be promoted. A specific result is erosion of the political will and
social capacity to reproduce the caring social institutions (health, education, child nurt-
uring) so essential for healthy societies (Bakker and Gill 2003). After thirty years of
making many errors with neo-liberal policies and their now-acknowledged adverse
impacts on health outcomes, there has been some return towards the 1978 Alma-Ata
ideals and the importance of primary healthcare—which includes action on the social
determinants of health—with a current emphasis on the provision of universal coverage,
 Global Politics of Healthcare Reform   461

although, as stated above, several proposed models to implement UHC threaten to

aggravate inequities in access (WHO 2008b).

Conclusion

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

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

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 chapter 24

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

Ted Schrecker

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

the one adopted in this chapter. Stated another way, the focus is not only on the explanatory
power of political economy as one among several competing approaches to global health
policy and politics, but also on the political economy of health in a global frame of refer-
ence (hereafter global political economy of health, or GPEH) and the roles of transnational
actors and processes. The mechanisms at work involve multiple channels or pathways,
including material deprivation (or its elimination in the case of improved standards of
living); the physiological effects of acute and chronic stress; the diffusion of unhealthy
lifestyles, including the unhealthy diets discussed at greater length later in this chapter;
changing levels of inequality and social cohesion; and changes in access to healthcare
and the benefits of medical technology (Cornia, Rosignoli, and Tiberti 2009; for elabor-
ations that do not specifically consider global influences, see Kelly and Doohan 2012;
Marmot and Sapolsky 2014; Whitehead et al. 2016).
Shortly before medical scientist Richard Feachem was appointed the first director of
the Global Fund to Fight AIDS, Tuberculosis and Malaria (the Global Fund), he argued
that ‘globalization’, defined in terms of increased openness to trade, ‘is good for your
health, mostly’ because of associated increases in national income that make possible
poverty reduction and investment in health systems (Feachem 2001, 504). This claim
was subsequently called into question on several counts. These included the difficulty of
establishing whether trade openness leads to growth or vice versa (reverse causation);
the basis on which ‘globalizing’ countries could be distinguished from ‘non-globalizers’;
the difficulty of distinguishing the effects of trade liberalization from those of other
policy changes and shifts in the external environment that occurred at the same time
(confounders; see Kawachi and Wamala 2007, 129–132); and an accumulating body of
evidence of the negative health impacts of trade liberalization (see ‘The political econ-
omy of trade and health’). An external evaluation of World Bank economic research on
growth and openness to trade, on which the Feachem claim relied, concluded that
‘much of this line of research appears to have such deep flaws that, at present, the results
cannot be regarded as remotely reliable, much as one might want to believe the results’
(Banerjee et al. 2006, 53). When the World Health Organization’s Commission on Social
Determinants of Health was established in 2005, one of its supporting knowledge net-
works1 dealt with globalization and synthesized the rapidly growing body of critical
work on health impacts (Labonté et al. 2009); in 2009, the third edition of a standard
text on international health appeared, with a critique of global economic integration as
the organizing theme for several chapters (Birn et al. 2009). By 2014 the authors of a
commissioned article in The Lancet on global governance for health (Ottersen et al.
2014) focused on ‘power asymmetries’ across a range of global health issue domains;
the concept also has relevance to the larger context of development policy (Abdulsamad
et al. 2015).
Although these are milestones in the literature, it must not be inferred that observers
of the politics of global health are in agreement, or that the trajectory of views on this
topic has been straightforward. For example, the index to the 900 pages of the most
recent edition of another standard international health text (Merson, Black, and Mills
2012) contains not a single reference to structural adjustment, the importance of which
 Critical Political Economy of Global Health   471

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

Structural Adjustment and

Neo-liberal Health System Reform

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

Schrecker 2005; Ambrose 2006; Working Group on IMF Programs and Health Spending
2007). IMF conditionalities were eventually applied to more than 75 countries (101 by
2008; Dreher, Sturm, and Vreeland 2015), with some countries involved in multiple loan
programmes for varying periods of time and achieving varying degrees of compliance
with their requirements.
The importance of structural adjustment for the political economy of health arises
from the impact of a relatively standard package of conditions, including reduction of
domestic subsidies and public sector expenditure (including healthcare), privatization
of state-owned assets, deregulation of domestic markets (especially labor markets, but
notably also markets for agricultural products), and increased openness to imports and
foreign direct investment in the interests of restructuring economies to improve their
export competitiveness (Kentikelenis 2017). Adverse effects on child health and well-
being were documented as early as 1987, in a UNICEF study of ten countries (Cornia,
Jolly, and Stewart 1987), whose argument for ‘adjustment with a human face’ seemed to
have little effect. Powerful descriptions of adverse health effects in Peru (Kim et al.
2000), sub-Saharan Africa (Schoepf, Schoepf, and Millen 2000), and the former Soviet
Union after the application of neo-liberal ‘shock therapies’ (Field, Kotz, and Bukhman
2000) appeared at the turn of the century; a rather sympathetic review for the World
Health Organization’s Commission on Macroeconomics and Health (Breman and
Shelton 2001, 2007) enumerated seventy-six studies of the health consequences of struc-
tural adjustment, identifying a preponderance of findings of negative health effects,
especially in Africa. More recent, multi-country statistical studies provide a clearer pic-
ture of negative effects, such as higher child and maternal mortality rates in sub-Saharan
African countries during periods in which they were operating under World Bank, IMF,
or regional development bank conditionalities (Shandra, Shandra, and London 2011;
2012; Pandolfelli and Shandra 2013; Pandolfelli, Shandra, and Tyagi 2014), while recog-
nizing the complexity of the relevant mechanisms of action. Hoddie and Hartzell (2014,
1040), in a study of all countries subject to IMF conditionalities between 1985 and 1989,
concluded that ‘the negative health consequences of SAPs [structural adjustment
programmes] are apparent in the immediate aftermath of signing an agreement as well
as years after the adoption of one of these types of loan programmes’, although the effects
did lessen over time. Such longer-term effects were observed (for example) by a devel-
opment assistance–funded team working in Tanzania’s public healthcare system: ‘The
era of structural adjustment may be over, but the effects of earlier damage continue to
cast a long shadow’ (de Savigny et al. 2004, 10). As noted, there is reason to question the
claim that the era was over.
The health system impacts of structural adjustment temporarily came to public atten-
tion in the wake of the 2014–2015 West African Ebola outbreak and the ‘secondary
health crises’ that emerged in such areas as nutrition, malaria treatment and maternal
care (O’Carroll 2014). Some observers argued that the weakness of national health
systems in those West African states most affected by the outbreak was directly traceable
to the legacy of IMF programmes (Rowden 2014; Kentikelenis et al. 2015), although
the IMF contested that claim (Gupta 2015). Another recent multi-country study of the
 Critical Political Economy of Global Health   473

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

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

The Political Economy of

Trade and Health

The coming into force of the North American Free Trade Agreement (NAFTA) in 1994
and the establishment of the World Trade Organization (WTO) regime in 1995 repre-
sented a fundamental change in the nature of trade policy and law. Successive rounds of
postwar negotiations under the General Agreement on Tariffs and Trade (GATT) led to
major reductions in tariffs and quotas, which operate at the border metaphorically if
not literally. These reductions had important short-term effects on the revenues avail-
able to many LMIC governments, because until recently tariffs still accounted for a far
larger proportion of their revenues than is the case in the industrialized world, and in
administrative terms they are far easier to collect than most alternative revenue streams
 Critical Political Economy of Global Health   475

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

High-Level Panel, 2016; Zhou 2016). The flexibilities sometimes are vitiated by ‘TRIPS-plus’
provisions in a variety of bilateral and regional trade agreements (Roffe, Von Braun, and
Vivas-Eugui 2008; Muzaka 2011; Lopert and Gleeson 2013). Numerous discussions of
the politics of access to medicines and IP protection are available in the literature (see,
e.g., Balasegaram, Childs, and Arkinstall 2014; ‘t Hoen 2016). A more basic problem of
political economy is that when medicines are produced primarily by profit-motivated
firms, little incentive exists to develop treatments for conditions that pri­ma­rily affect the
poor: ‘[I]t is more profitable to develop and market Viagra than to research a new drug
to treat patients with visceral leishmaniasis, a fatal disease if left untreated. Such a drug
is more likely to be developed through veterinary research if it has economic potential
on the pet market’ (Veeken and Pécoul 2000, 309).
Two other areas of impact demonstrate the importance of a political economy per-
spective; each arises from the fact that contemporary trade seldom involves the textbook
process of arm’s-length exchange of goods between producers located in two relatively
discrete national economies. Rather, it has been estimated that 80 percent of world trade
now involves complex commodity or value chains that operate across multiple national
borders and are controlled by transnational corporations (TNCs) (UNCTAD 2013).
Thus, contemporary trade agreements are about protecting or incentivizing investment
as much as they are about conventional notions of trade. In many cases they are also
(indirectly) about producing illness, in the form of people being overweight or obese.
The link operates by way of an increasingly globalized food system, and associated
‘nutrition transitions’ toward commercially produced, energy-dense, and ultra-processed
foods (Popkin, Adair, and Ng 2012; Monteiro et al. 2013; Malik, Willett, and Hu 2013;
Anand et al. 2015). ‘[T]he main driving force now shaping the global food system is
transnational food manufacturing, retailing and fast food service corporations whose
businesses are based on very profitable, heavily promoted ultra-processed products,
many in snack form’ (Monteiro et al. 2013, 21).
Generically, liberalization of trade and investment greatly facilitated foreign invest-
ment in supermarkets, food processing and fast food, and imports of ultra-processed
products (Hawkes et al. 2012; Friel et al. 2013b), such that the prevalence of overweight
and obesity in some middle-income countries—such as Mexico (Clark et al. 2012)—is
now comparable to that in the high-income world. Hawkes et al. (2012, 344) argue that
SAPs were the first of ‘two main policy processes’ that led to transformation of the food
system in LMICs, with trade agreements being the second. Public health researchers are
expressing particular concern about the potential that ‘mega-regional’ trade agreements
now under negotiation or awaiting ratification will further limit the ability of governments
to address this phenomenon, for example by limiting options for labeling requirements
and taxation of unhealthy diets (Gleeson and Friel 2013; Friel et al. 2013a; Thow et al.
2015). The background is a formidable corporate research and marketing apparatus
dedicated to promoting processed food products that are highly profitable but may be
unhealthy (Moss 2013) and to resisting regulatory or even public information initiatives
(Taubes and Couzens 2012; Freudenberg 2014, 37–123; Kearns, Glantz, and Schmidt 2015).
 Critical Political Economy of Global Health   477

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

Future Directions and Challenges

The preceding discussion has been selective. It has not considered such questions as the
long-term impact of the post-2007 financial crisis, the quintessential manifestation of
the downside risks of economic integration and their unequal distribution: on health
directly; through the macroeconomically misguided policies of selective austerity that
have been the predominant response (Stuckler and Basu 2013; Basu, Carney, and
Kenworthy 2017), and by ratcheting up economic inequality. It has not addressed the
complex challenge of antimicrobial resistance (Laxminarayan et al. 2013), although this
seems a natural topic from a political economy perspective because it represents one of
the few truly global ‘public bads’ (i.e., avoidance is a global public good) and because the
private incentives for contributing practices, such as overuse of antimicrobials in veter-
inary practice, invite the externalization of costs. It has also dealt only with one dimen-
sion of the political economy of non-communicable diseases—the connection with
liberalization of trade and investment—despite their clear importance to the global bur-
den of illness and the value of a political economy perspective in addressing both the
power dynamics of the corporate contribution to NCDs and the (much less well under-
stood) lack of support through development assistance for NCD-related policies and
interventions (Nugent and Feigl 2010). The process by which NCDs became more
prominent on the global health policy agenda, and the influences on priority setting
within that agenda, invite further investigation from a political economy perspective
(Glasgow and Schrecker 2015).
This partial list of omissions simply serves to suggest a range of research topics that
are likely to yield improved understandings of the role of political and economic struc-
tures in producing health and illness (as explicated by Krieger 2011) and the importance
of the power asymmetries foregrounded by Ottersen et al. (2014). Here I identify two
such lines of inquiry, one primarily empirical and the other primarily normative,
although it draws on solid empirical foundations.
It is now almost a cliché to assert that divisions between ‘developed’ and developing
worlds, the center and the periphery, or the global North and the global South, are shift-
ing and mutating. This is happening in at least two respects. First, as defined by the distri-
bution of economic activity, the world’s center of economic gravity is shifting to the south
and east (Dobbs et al. 2012, 16–17), a phenomenon exemplified but only partly captured
by the rise of the so-called BRICS countries (Brazil, Russia, India, China, and South Africa)
and other blocs of emerging economies (United Nations Development Programme 2013,
43–61) and by the growing number of TNCs headquartered outside the high-income
world. Second, and probably with more substantial and immediate consequences for
health, economic inequalities within national borders are growing as a consequence of
economic integration and (in many cases) neo-liberal domestic policies.
Before NAFTA and the WTO regime came into force, journalist Walter Russell Mead
(1992, 42) predicted that as a consequence of economic integration, ‘The First and Third
 Critical Political Economy of Global Health   479

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

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

Note
1. Full disclosure: coordinated by the author.
 Critical Political Economy of Global Health   481

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 pa rt I V

IS SU E S I N
GL OBA L H E A LT H
P OL I T IC S
 chapter 25

The H um a n R ight to
Hea lth a n d Gl oba l
Hea lth Politics

Gorik Ooms and Rachel Hammonds

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

health inequalities unrelated to infectious disease. From a constructivist perspective,

the most likely candidate for a norm that states may want to comply with, because they
value the norm itself, is the human right to health, as enshrined in the International
Covenant on Economic, Social and Cultural Rights (ICESCR), the Convention on the
Rights of the Child, and other international human rights law treaties. Other norms, like
the Millennium Development Goals (MDGs) and their successors, the sustainable
development goals (SDGs), may play a similar role. From an international law perspec-
tive, they do not have the same authoritative value as a legally binding treaty, but they
may have more political value and therefore more influence on global health politics.
The influence of the human right to health on global health politics can be explored
from numerous angles. We focus in this chapter on two distinct approaches, the normative
and the descriptive, each of which answers different types of questions. The normative
approach employs right to health norms to depict what governments (and other actors)
ought to do so as to describe how global health politics would look if the right to health
drove politics. The descriptive approach examines the reality of global health politics
to understand why global health’s ‘politicians’ do what they do, to determine the extent
to which global health politics is influenced by the right to health. Combining both
approaches is more illuminating. A strictly normative approach would lead to a descrip-
tion of an ideal type of global health politics that bears little resemblance to the present
reality. Furthermore, it would contain many lacunae, as the human right to health is
essentially a principle that requires further crystallization through application in real
life, as explained below. A strictly descriptive approach would be difficult; if we do not
know what right to health compliant global health politics should look like, we cannot
judge whether the world is moving toward it (or not).
Combining both approaches requires a note of caution. While both the normative
and descriptive approaches can illuminate the same topic, they belong to different
­epistemological dimensions. They look for, or claim, distinct kinds of truths. These
statements—(a) because of the law, cars on this highway should not drive faster than
120 kilometers per hour (kmh) and (b) cars on this highway are not driving faster
than 120 kmh because of the law—may look very similar but are quite different.
Statement (a) can be true, even if all cars are driving much faster than 120 kmh. This is
because it is a normative statement, which can be true even if the empirical reality
seems to tell a different story. Furthermore, even if all cars drive at 120 kmh or slower,
statement (b) could still be untrue. For example, drivers may not care about the law, but
respect the speed limit out of fear that faster driving could damage their cars. Thus, even
when we observe global health politics that is in line with the right to health, it does not
necessarily mean that it is in line with the right to health because of the right to health.
We therefore divide this chapter into two sections. The normative section briefly
explores what global health politics should do to be compliant with the right to health,
then discusses three main obstacles to greater compliance. First, we examine the post–
World War II evolution of human rights, from citizens’ rights to human rights. Second,
we explore the legacy of the historical cleavage of human rights into two international
treaties, the ICESCR, often characterized as costly entitlements, and the International
 Human Right to Health   495

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

The Normative Approach to

Health as a Human Right

From Citizens’ Rights to Human Rights

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

Rights, that among these are Life, Liberty, and the pursuit of Happiness’, but many of the
signatories saw no contradiction in being slaveholders. Both documents were declar-
ations of the rights of citizens of given countries, and the corresponding duties rested
upon the governments of these countries. These were not human rights declarations.
The world wars during the twentieth century, and World War II in particular, forced a
revision of the concept. If human rights were only citizens’ rights, then the rights of
German citizens under Nazi rule may have been only those rights recognized by Hitler’s
government. This was untenable. The 1948 Universal Declaration of Human Rights
(UDHR) refers to the atrocities of World War II and proclaims the human rights of ‘all
human beings’ (article 1), ‘everyone’ (articles 2, 3, 6, etc.), and ‘all’ (article 7). Thus, the
UDHR seems to leave little ambiguity about the nature of the rights it proclaims: that is,
human rights, not citizens’ right. However, some ambiguity remains because of the way
the corresponding duties are allocated in the UDHR. On duties, the UDHR remains
ambiguous. On the one hand, it seems to place the corresponding duties upon humanity:
‘Member States have pledged themselves to achieve, in co-operation with the United
Nations, the promotion of universal respect for and observance of human rights
and fundamental freedoms’. On the other hand, the UDHR calls itself ‘a common stand-
ard of achievement for all peoples and all nations’. Thus, the duties seem to remain with
states, or more precisely, ‘all peoples and all nations’.
Does the ambiguity about corresponding duties affect the nature of the rights of
humans or citizens? Much has been written about the relationship between rights and
duties. To briefly summarize, some scholars argue that a human right only qualifies as
such if it is enforceable; it is ‘essential to the existence of a set of “rights” that there be
some specifiable, and more or less effective, mechanism for enforcing them’ (Geuss
2001, 143). If this is so, then being held as a slave was not a human rights violation as long
as some states tolerated or promoted slavery (and other states did not intervene); the
essence of the right to freedom sprang into existence when all states agreed to abolish
slavery. Other scholars argue that human rights only qualify as such when they are at
least claimable, when the duty bearers and the content of the duty can be identified
(O’Neill 1996). Whether the duty bearers do live up to their duties is a different matter;
what matters is that they should: that is enough for rights owners to have a legitimate
claim. Some scholars agree with this ‘claimability’ condition but defend a softer version
of it: it is not essential that the duty bearers can be clearly identified or that the extent of
their duties is clearly defined; what matters is that duty bearers are identifiable in theory,
if not in practice (Griffin 2008). If the links between duty bearers and duties are not
clear, it only means that more work needs to be done to clarify them. However, it is
essential that some people or institutions, somewhere on the earth, are able to fulfill the
corresponding duties.
We side with the soft version of the claimability condition: a human right can only be
a human right if it is possible, at least in principle, to identify people and institutions
who can, together, ensure that right to all human beings. If no institution or collective of
institutions is able to ensure a given right to all humans, the claim is void. If it is possible
to imagine how institutions could ensure a given right to all humans, the claim has
 Human Right to Health   497

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

claim is sufficient, as long as it is possible, at least in principle, to identify people and

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

The meaning of the international obligation to co-operate for the purpose of realizing
the right to health is far from settled. But its ambiguity and contested nature, espe-
cially in the context of international assistance, are not sufficient grounds to relegate
this obligation to the periphery in any discussions concerning the right to health.
On the contrary it must occupy a more central place given that co-operation
 Human Right to Health   499

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

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

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

Freedoms versus Entitlements: Implications

for Global Health Politics
For many global health scholars, stating that health is a human right makes little sense. It
sounds as though all humans have an entitlement to be healthy, and that is like saying
that all human beings have an entitlement to be happy. However, like other human
rights, the right to health is a kind of shorthand. It is not a right to be healthy but a legit-
imate claim to a basket of freedoms and entitlements that can have a positive impact
on one’s health. For example: both the entitlement to healthcare and the freedom to
criticize the government for not providing adequate healthcare can have a positive
impact on one’s health.
We explained previously that the difference between human rights freedoms and
entitlements was a key reason for the elaboration of two different covenants: the ICCPR
and the ICESCR. This division has been criticized by many human rights scholars as
artificial and misleading. However, while we prefer more sophisticated typologies that
reveal the intellectual kinship of all human rights—such as those suggested by Shue
(1996) and Eide (2001)—not only has the division resulted in different treaties, entailing
different legal obligations, it is also rooted in reality. If all human rights are legitimate
claims to mixed baskets of entitlements and freedoms, and no human rights consist of
only claims to freedoms or only claims to entitlements, it is clear that in some human
rights baskets one will find more freedoms than entitlements, and vice versa. Freedom
of speech, for example, does require an entitlement to protection against retaliation by
those who do not want certain opinions to be voiced—a journalist who wants to write
 Human Right to Health   501

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

The Human Right to Health as a Lever, Not a Force

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

However, when it comes to compliance at the global level, we cannot take for granted
the commitment to human rights of these states. First, while Canada, France, Germany,
Japan, Norway, and the United Kingdom have ratified the ICESCR, the United States has
not. Second, as discussed previously, the shift from citizens’ rights to human rights has
only recently begun and is far from complete. As Tobin (2012, 340) notes, several states
have argued that ‘although the need for international co-operation and assistance
reflected an “important moral obligation”, it was “not a legal entitlement”.’ Third, all
these states have interests that may be at odds with global health politics aligned with the
right to health: to avoid being obliged to pay for healthcare for other states’ citizens, but
also, for example, to continue recruiting health workers from countries where they are
needed more, without being labeled a human rights violator. Therefore, we should not
expect these states to live up to their international duties unless non-governmental
actors pressure them into it.
If the substance of the human right to health remains somewhat vague; if, a fortiori, the
substance of the international duties for the realization of the right to health remain vague;
and if on top of that, we can only expect states to act upon their international duties if
NGOs use the right to health as a lever for their claims, then the role of NGOs in advancing
the right to health is more than a strategic one. It becomes a defining one. The successful
right to health claims advanced by NGOs upon the global health politics of influential
states are not only contributing to the realization of the human right to health, they are also
defining the substance of the right to health. For example, before HIV/AIDS activism
claimed that access to ARVs is an essential element of the right to health, before UNAIDS
and the Office of the High Commissioner on Human Rights (OHCHR) confirmed this
claim in 2002 (UNAIDS and OHCHR 2006), before ARVs were added to WHO’s essential
medicines list (also in 2002, and under HIV/AIDS activist pressure) (Laing et al. 2003),
and before the creation of a mechanism that allowed the practical international cooper-
ation required (again in 2002, i.e., the Global Fund), few lawyers would have unequivo-
cally confirmed that access to ARVs is an essential and universal element of the right to
health. Since then access to ARV therapy has been cited as a textbook example of the right
to health (Wolff 2012; Tobin 2012; Griffin 2008; Chapman 2016).
We therefore agree with Tobin (2012, 368) when he argues that ‘[t]he meaning of the
international obligation to co-operate for the purpose of realizing the right to health is
far from settled’, and that the challenge remains ‘to provide a persuasive interpretation
that can outline the “concrete measures” required for its effective implementation’. This
is a challenge not only for legal scholars but also for global health scholars and NGOs.
While we would have liked to end this normative section with a clear and detailed over-
view of what states ought to do in global health politics to support the human right to
health, that is not possible. The 2000 General Comment (United Nations International
Committee on Economic, Social and Cultural Rights 2000) contributed greatly to
clarifying the contours of the right to health; however, it leaves many important issues
unsettled (Forman et al. 2013). As Chapman (2016) argues, the human right to health is
an emergent human right; it has not fully crystallized yet, and that is particularly true for
its international dimension.
 Human Right to Health   503

The Descriptive Approach to

Health as a Human Right

HIV/AIDS, the Right to Health, and Global Health Politics

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

Agreement Establishing the World Trade Organization (Gervais 2012). Thus, TRIPS was
part of a package deal, a part strongly promoted by many industrialized countries and
reluctantly accepted by most low-income countries, as a price to be paid for WTO mem-
bership (Correa 2000). The agreement obliged WTO members to adopt minimum
standards for intellectual property protection. This in turn had a direct effect on the cost
of ARV medicines. In the words of Stiglitz (2008, 181), ‘when the trade ministers signed
the trade agreement in Marrakech in April 1994, they were in effect signing the death
warrants for thousands of people in Africa and other developing countries’.
The TRIPS agreement included some flexibilities, including the possibility for gov-
ernments to issue ‘compulsory licenses’ and thus to allow manufacturers of medicines
to produce generic (and much cheaper) copies of patent-protected medicines, without
the patent owner’s permission. Brazil used this flexibility as part of its strategy to pro-
vide free ARV treatment (Galvão 2005). South Africa adopted the South African
Medicines and Medical Regulatory Devices Act in 1998, which allowed a systematic use
of TRIPS flexibilities. A coalition of pharmaceutical companies sued the government
of South Africa. Activists from all over the world mobilized against the pharmaceut-
ical companies. In April 2001 the coalition of pharmaceutical companies withdrew its
lawsuit (Brier 2009).
According to Barnard (2002, 167), the framing of the lawsuit’s withdrawal as a victory
of ‘the requirements of justice and respect for human rights’ was ‘seriously misleading’,
because most countries in Africa were too poor to provide ARV treatment even at
reduced costs. But global HIV/AIDS activism did not stop with the end of the lawsuit. In
the same month Harvard University faculty members issued the ‘Consensus Statement
on Antiretroviral Treatment for AIDS in Poor Countries’. ‘As individuals committed
to equitable access to health care for all peoples and to human rights’, the statement
acknowledged that ‘AIDS treatment will always be more expensive than poor countries
can afford, meaning that international aid is key to financing the effort’ (Individual
Members of the Faculty of Harvard University 2001). It called for a global fund to help
developing countries finance AIDS treatment. Echoing the 1989 Montreal Manifesto,
this became the next target of global HIV/AIDS activism. When the Global Fund was
finally up and running in 2002, allowing the rollout of a global AIDS treatment effort,
helped by the President’s Emergency Plan for AIDS Relief (PEPFAR), HIV/AIDS activ-
ism successfully challenged the practice of making patients pay ‘user fees’ (Souteyrand
et al. 2008) and the imposition of expenditure ceilings by the World Bank and the
International Monetary Fund (Rowden 2013; Baker 2010).
Did AIDS activism ‘create’ a new and universal right to health entitlement? That
would be at odds with the concept of human rights: ‘rights held by individuals simply
because they are part of the human species’ (Ishay 2008) and therefore not dependent
on the willingness (or not) of states to ensure their enjoyment. In our opinion, AIDS
activism ‘clarified’ one element of the right to health, helping one element of the right to
health to ‘emerge’ from the ambiguities and weaknesses of the international treaties’
texts. Other elements are waiting to be ushered in.
 Human Right to Health   505

Health for All, the Right to Health, and Global

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

was a ‘two-pronged program—aimed at securing an equitable distribution of the world’s

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

Universal Health Coverage, the Right to Health,

and Global Health Politics
The World Health Report: Primary Health Care (Now More Than Ever) signaled WHO’s
return to the aspirations of the Declaration of Alma Ata (WHO 2008; Chan 2008). This
report introduced the concept of UHC to a wider audience. WHO presented UHC as ‘a
practical expression of the concern for health equity and the right to health’ (WHO 2012).
 Human Right to Health   507

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

Conclusion

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

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

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 chapter 26

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

Sara E. Davies

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

account ‘sources other than [the state] for notifications or consultations’ and ‘assess
these reports according to established epidemiological principles and then communicate
information on the event to the State Party in whose territory the event is allegedly
occurring’ (article 9.1). In 2016 more than 60 percent of WHO’s first news of outbreak
reports came from ‘unofficial sources’ (sources other than the state), which include
electronic media, discussion sites, social media, and Internet surveillance response
programmes (ISRPs) (WHO 2016). Referred to as ‘digital disease detection’ (DDD),
ISRPs trace ‘big data’ patterns in cyberspace to detect risk, as well as scan news and
media websites for higher than usual reports of disease outbreaks (Lazer et al. 2014;
Vayena et al. 2015). Big data algorithms are constantly finessed to predict the next out-
break. This includes text mining of social media pages; doing Google searches on terms
such as ‘flu’ or ‘outbreak’; and tracking human behaviours such as purchasing patterns
from pharmaceutical sites, the monitoring of local news reports, and filtering social
media discussions on platforms such as Twitter, Facebook, and Weibo. These methods
supply ISRPs—and potentially WHO—with early reports or rumours of novel disease
outbreaks (Roberts and Elbe 2016). A recent example of how this method works is the
tweeting activity surrounding the first case of Ebola haemorrhagic fever in Nigeria in
July 2014, which occurred days before official confirmation by the Nigerian government.
In this case, rather than seeing social media as a site of unverified rumours, the Nigerian
government harnessed social media to good effect to communicate the spread of the
outbreak (Odlum and Yoon 2015).
However, the ISRPs conducting DDD continue to attract controversy and face chal-
lenges, largely centred on the presumed benefits of digital detection relative to more
traditional public health surveillance and response and questions of whether the former
undermine the latter. The advantage of digital detection is that it has the potential to pre-
pare communities and governments to contain a deadly outbreak (Brownstein, Freifeld,
and Madoff 2009). However, ISRPs cannot mount investigations into outbreak rumours,
nor can they erect containment responses; the WHO director-general (DG) and the
government of the affected state are the only actors with the authority to act on rumours
supplied by an ISRP. Acting on informal rumours carries great political risk, especially
for WHO. As the Ebola outbreak in West Africa in 2014 tragically demonstrated, ISRPs do
not exist primarily because WHO is often uninformed about an outbreak. Rather, ISRPs
exist because nonstate actors have and will report against the wishes of governments
that seek to deny the existence or extent of an outbreak (Ebola Interim Assessment Panel
2015, 10). This has the potential to put WHO on a collision course with some of its mem-
ber states.
Other questions pertain to the ethics of data collection and usage and the lengths
ISRPs may go to in conducting individual-level surveillance required for digital detection
in the name of health security. Critics of big data contend that public health surveillance
that relies on digital methods facilitates the growth of the surveillance state. The danger
here is that excessive surveillance could be legitimised in the name of health security,
raising difficult questions about how to balance the demands of public health and the
individual’s right to privacy (Calain and Abu Sa’Da 2015; Vayena et al. 2015). This is a
 Reporting Disease Outbreaks    515

particularly pressing question in politically suppressive states, where the information

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

The Challenge: ISRPs’ Right to

Report (and to Be Heard)

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

This raises the question of under what authority WHO—a body whose membership
consists solely of states—can receive reports from nonstate actors about a disease outbreak
located in a member state. When states adopted the revised IHRs in May 2005, they
agreed to openly and promptly report outbreaks with the potential for ‘international
spread’. What was significant about the IHRs’ revision was a shift from a model focused
exclusively on alerting the international community about an outbreak (and taking rele-
vant quarantine measures) to the adoption of a ‘legal instrument [that sought] to ensure
global health security through a collective approach’ (Li and Kasai 2011, 7). Pre-emption
was the goal attached to the revised IHRs, and this marked out the importance of report-
ing: states have to know in order to contain. Baker and Fidler (2006, 1062) argue that one
particular strength of the revised IHRs was the inclusion of a provision in article 9 that
permitted WHO to receive reports of disease outbreak events from sources other than
the affected state.1 They argue that article 9’s significance lies in the potential for WHO
to ‘cast its surveillance network beyond information it receives from govern-
ments. . . . [This would] avoid being blocked by governmental failure to comply with
reporting requirements’.
The significance of article 9 lies in the expectation that to facilitate a transparent sur-
veillance and reporting system, WHO must be permitted to receive reports of disease
outbreaks from sources other than the state. Despite World Health Assembly (WHA)
approval of this practise in the 2001 resolution ‘Global Health Security’ (WHA 2001), it
was a contentious practise during the SARS outbreak in 2003 (Cortell and Peterson
2006; Kamradt-Scott 2015). In addition to reports from health ministries, the WHO
Secretariat relied upon reports from media, scientists, and individuals about suspected
SARS outbreaks (Heymann and Rodier 2004; Heymann, Mackenzie, and Peiris 2013). In
the case of China, the state reported to WHO headquarters (for some months) a very
small SARS caseload, whilst WHO was simultaneously being informed by nonstate
sources within and outside China that the extent of the infection was much greater
(Fidler 2004). Controversially, WHO used these reports to request the Chinese govern-
ment check its cases, issued travel advisories against the country, and publicly rebuked
the government for not revealing the full extent of the SARS virus, particularly in
Beijing. The fact that WHO’s use of nonstate reports was formally adopted under article
9 in the revised IHRs, agreed to in the aftermath of SARS, was regarded as a vindication
of the WHO DG’s efforts to demand more reporting transparency from states and
to attach consequences to lack of transparency (Mack 2007). The revised IHRs were
considered a ‘new dawn’ for global health, whereby WHO may receive reports from
nonstate sources and act upon them to elicit further information from a recalcitrant
state (Rodier 2007).
Since the euphoria over article 9, little discussion has followed addressing the chal-
lenge of realising its promise. In particular, how does WHO persuade affected states of
the need to investigate outbreak reports issued by nonstate actors? And how does WHO
respond to outbreak reports from nonstate actors that appear credible but are denied by
the host state? The advantage of article 9 is that it permits WHO to listen to other sources
and not solely rely on a government, particularly if that government is suspected of
 Reporting Disease Outbreaks    517

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

analysts with language proficiency in Arabic, Farsi, English, Spanish, Russian, Chinese,
Portuguese, and French can sift through thousands of reports daily to determine which
ones should be placed on the subscriber-only alert page (which can also be emailed to
subscribers). GPHIN was developed in a partnership between WHO headquarters
and the Public Health Agency of Canada in 1996. It was one of the first ‘real-time’ sur-
veillance networks, and originally reports were only issued to fee-paying subscribers.
GPHIN, whose staff are all Public Health Agency of Canada employees, has gone
through various iterations and is currently a 24/7 early warning system for infectious
disease outbreaks that is open source to any subscriber. ProMED has been providing
infectious disease alerts to its subscribers since 1994, using volunteer moderators and
analysts. It has been aligned with the International Society for Infectious Diseases since
1999 and relies on donations for support. ProMED reports are published on the
HealthMap site (http://www.healthmap.org/en/), and they now share a visual world map
of disease outbreaks that is updated 24/7. ProMED describes itself as ‘open to all sources
and free of political constraints. Sources of information include media reports, official
reports, online summaries, local observers, and others’ (ProMED 2016). There are sev-
enty thousand subscribers to ProMED across 185 countries.
Contemporary Internet-based health surveillance tools use various techniques to
report (mostly) infectious disease outbreaks. Some primarily use text mining of media
reports for disease outbreak events (e.g., MedISys);3 others incorporate algorithms,
media reports, and correspondence from users, which are distributed to subscribers
(e.g., ProMED, GPHIN). Still others attempt to refine ontology software so that it may
conduct both text mining and language translation for reports (e.g., PULS Project:
Surveillance of Global News Media).4 To date, GPHIN and ProMED are the longest
serving infectious disease surveillance networks and the only two to rely on human ana-
lysts prior to online publication of reports. When GPHIN or ProMED reports a disease
outbreak that has not been confirmed by a state, tensions have and can immediately
escalate if that state did not want the outbreak reported (Madoff and Woodall 2005).
In previous situations, including the Nipah virus outbreak in Malaysia (1997), SARS in
China (late 2002), and MERS in Saudi Arabia (2012), direct notification of these out-
breaks from ‘informal’ channels (healthcare workers, laboratories, and ‘laypersons’) has
been made at great personal risk (Madoff and Woodall 2005; Branswell 2013b; Dion,
AbdelMalik, and Mawudeku 2015).
The capabilities of ISRPs vary widely in both type and performance (Castillo-Salgado
2010, 98–100; Hartley et al. 2010, 3). The type of intelligence generated depends on each
ISRP’s functionality, accuracy, and coverage. However, the right to act on these reports
rests with WHO, specifically the WHO DG, and the political consequences of using such
reports explain the variation in their use by successive DGs. Gro Harlem Brundtland,
for example, proactively sought to forge relationships with ISRPs, and WHO epidemi-
ologists within the infectious disease section often formed partnerships to investigate
reports (Grein et al. 2000). Her successor, Lee Jong-wook, also promoted a series of
global surveillance systems—global tuberculosis, global vaccine immunisation, and
global polio surveillance—that have retained nonstate- and state-informed surveillance
 Reporting Disease Outbreaks    519

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

The Controversy from

Nonstate Reports

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

reliably come from affected states), (b) its right to acquire information from nonstate
sources, and (c) the need for state verification to proceed with outbreak response
recommendations:

Although WHO has a broad mandate to share urgent information on public-health

events, WHO usually obtains agreement first from the affected State Party. The
proc­ess of consulting with States Parties may delay posting on the EIS [Event
Information System]. There is an inherent tension between WHO’s obligation to
inform other States Parties and the affected State Party’s interest in avoiding poten-
tial social and economic consequences. WHO tries to balance these priorities and
sensitivities through dialogue, respecting the requirements in Article 11. For the EIS
to become an even more valuable tool, States Parties should be more willing to let
WHO share information. The WHO EMS was developed to track information on
public-health events. (IHR Review Committee 2011, 54)

In 2015 the Ebola Interim Assessment Panel, appointed by the WHO DG to examine
the organisation’s performance during the 2014 outbreak in West Africa, reinforced this
view. It noted that member states have ‘largely failed’ to implement the IHRs’ core capaci-
ties, since no functional in-country surveillance was available to detect the extent of an
infectious disease outbreak (Ebola Interim Assessment Panel 2015, 11). In addition, the
panel noted a deliberate intention by the states most affected by the outbreak (Guinea,
Sierra Leone, and Liberia) to delay their own government-issued reports whilst denying
outbreak reports from nonstate sources. Despite the authority of WHO to investigate
these nonstate reports, and despite repeated warnings from nonstate actors that the situ-
ation was grave, WHO senior management did not challenge the actions or denials of
these states (Ebola Interim Assessment Panel 2015, 12). How can we explain such confu-
sion if article 9 is as clear-cut as others have argued? To help answer this question, we
now examine an earlier case, the first outbreak of MERS in Saudi Arabia in 2012.
In June 2012, a patient with a severe respiratory disease was admitted at the Dr
Soliman Fakeeh Hospital in Jeddah, Saudi Arabia. When the patient did not improve,
Dr Ali Mohamed Zaki, an Egyptian national and professor of microbiology at the hos-
pital, took a sample of sputum to identify the cause of the sickness. When he could not
detect a positive for any of the suspected diseases, he contacted Dr Ron Fouchier at
Erasmus Medical College in Rotterdam, Netherlands. Suspecting a novel virus, Dr Zaki
sent a sample to be tested in Dr Fouchier’s lab. Dr Zaki argues that he ‘complied with
procedures by submitting a virus sample and associated clinical data to the Saudi
Ministry of Health on 18 June’ (Butler 2013). There was no follow-up from the health
ministry, so he continued to cooperate with Dr Fouchier’s lab. The Saudi Ministry of
Health has since said that it does not deny regular procedures were followed, but that
Dr Zaki did not inform them that the sample was suspected to be a novel virus (Butler
2013). In September, Dr Fouchier reported to Dr Zaki that the Erasmus lab had detected
a novel coronavirus (Zaki 2012).
Two events then had an immediate impact on Dr Zaki. On the same day that he noti-
fied the Saudi government of the coronavirus finding by the Erasmus lab, he notified the
 Reporting Disease Outbreaks    521

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

only official sources on the disease. The Ministry of Health allegedly advised healthcare
workers that they could be imprisoned for disclosing any information issued by the
ministry, which included information on infectious disease outbreaks (Al Omran et al.
2014). The same month, the health minister and deputy health minister were fired for
allegedly failing to disclose full reports (Branswell 2015). After the WHO visit, the Saudi
government released a statement claiming that it would review procedures for reporting
cases (Ministry of Health Saudi Arabia 2014), but some governments (United Kingdom)
and regional organisations (i.e. European Centre for Disease Prevention and Control)
continued to express concern about the limited amount of information coming out of
the region about the virus, fuelling ongoing queries about the timeliness of and full
details being provided in outbreak reports (European Centre for Disease Prevention
and Control 2014; Branswell 2015).7
Very little was said about the Saudi government’s transparency regarding MERS by
WHO, which is what made comments at the 2013 WHA from its DG (Dr Chan) all the
more curious. In May 2013, Saudi Arabia deputy health minister Zaid Memish had pre-
sented to the WHA the MTA placed by the Erasmus lab on its sample of MERS (which
had been sent by Dr Zaki). Dr Memish argued that this MTA had prevented the Saudi
government from studying the virus to improve its own diagnostics. Dr Chan not only
sided with Dr Memish, but also argued in her subsequent speech at the WHA that dele-
gates must ‘share your specimens with WHO collaborating centers, not in a bilateral
manner. Please, I’m very strong on this point, and I want you to excuse me. Tell your sci-
entists in your country, because you’re the boss. You’re the national authority. Why would
your scientists send specimens out to other laboratories on a bilateral manner and allow
other people to take intellectual property rights on a new disease?’ (Fidler 2013).
David Fidler and others have argued that this statement, which was supported by
WHO assistant general for health security and environment Keiji Fukuda, was not only
incorrect but carries serious implications for future Dr Zakis and ISRPs (Butler 2013;
Fidler 2013). Chan’s comments—insisting on national authority over specimen control—
gave no consideration to Dr Zaki’s claim that he had approval to send the virus, nor did
it acknowledge the importance of his alert to ProMED, which spurred international
action to detect the virus. The ProMED report directly led to a patient in London being
tested for the virus in the same month, and in effect alerted the international commu-
nity to the new disease (Zaki et al. 2012). Dr Chan’s exhortation to ‘[t]ell your scientists
in your country, because you’re the boss’ has implications beyond situations in which
scientists need international assistance to diagnose an outbreak. This statement does
not acknowledge the right of the nonstate actor to report despite its inclusion under
article 9 of the IHRs.
In this case, there was an obvious tension between supporting a national government,
virus sample sharing, and rapid diagnosis, especially in a situation where the state was
unable to diagnose the pathogen but wanted to maintain control over the reporting of the
outbreak and the use of sample(s). There was a further tension here because WHO wanted
to be part of the diagnostic process and resented others such as Erasmus and ProMED
 Reporting Disease Outbreaks    523

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

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

Conclusion

The existing ISRPs face multiple hurdles, including creating uniformity in reporting to
build trust in the concept of DDD, the capacity to differentiate to survive competition,
and the proficiency to provide timely and accurate reports whilst complementing—not
competing with—state surveillance activity. The existence of a provision to permit
nonstate reports under the revised IHRs legitimises WHO’s receipt of such reports and
taking action based on them. As such, the challenge and controversy that has arisen
during H1N1, MERS, and Ebola outbreaks may point to WHO’s dereliction in fulfilling
the promise of article 9. But WHO’s wariness to openly challenge a state’s report on the
basis of information received under provisions of article 9 also points to what was for-
gotten when the IHRs were adopted in 2005. It is not only WHO headquarters that
wants to know of an outbreak that could risk health and trade. All states want to know,
and they especially want to know if it is on their borders. States agreed to article 9 in part
because of the inevitability of information leakage, and because the IHRs included the
provision for states to develop their capacity to manage the detection process and com-
munications required during an outbreak. The critical challenge that ISRPs and WHO
may continue to face is political blowback from states that do not want outbreak events
to be reported on these sites. To date much concern has focused on the potential uneth-
ical use of surveillance methods to collect big data. This chapter has revealed that whilst
those concerns remain legitimate, it is equally important to remain attentive to the ex­ist­
ence of political situations in which excessive reporting restrictions may impede data
collection during disease outbreak emergencies.
 Reporting Disease Outbreaks    525

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

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 chapter 27

The Politics of
Pa n demic I n flu enz a
Pr epa r edn ess

Adam Kamradt-Scott

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

From Disaster to Discovery

and Global Surveillance

Influenza epidemics and pandemics have been regular features of human existence for
the better part of one thousand years. Indeed, the first record of an influenza epidemic
was documented to have adversely affected England, Germany, and Italy in 1173 ce
(Cunha 2004). The first influenza ‘pandemic’ (defined as affecting two or more regions)
appears to have occurred around 1510, having spread from northern Africa into the
Middle East and then to Europe (Quinn 2008). Over the next four hundred years
influenza epidemics and pandemics were recorded with such frequency that they were
statistically evaluated to occur on average once every 19.8 years (Eichel 1922). Crucially,
however, throughout this extensive history of human interaction with influenza the
etiological agent responsible—a virus—remained undiscovered until the start of the
twentieth century, with various explanatory theories ranging from the wrath of the gods
to cosmological events and foul-smelling mists (or ‘miasma’) (Patterson 1986).
The 1918 Spanish influenza pandemic remains to this day one of the four most signifi-
cant epidemiological events in recorded human history. This one event, which spanned
approximately an eighteen-month period around the end of World War I, resulted in the
death of an estimated forty million people worldwide. The case fatality ratio (number of
deaths divided by the number of infections), at 2.5 percent, was comparatively high
compared to seasonal influenza (Taubenberger 2006), but critically, it is important to
appreciate that the vast majority of people infected—some 97.5 percent globally—actu-
ally survived. During the 1918 pandemic a number of farmers had noted that a similar
illness had appeared in pigs, and this observation then prompted a group of scientists to
investigate whether a correlation existed (Smith, Andrewes, and Laidlaw 1933). In 1933 it
was discovered that a virus was responsible for causing influenza, and that influenza did
indeed have the ability to move between different species (i.e., it was zoonotic).
As a direct consequence of the severe morbidity and mortality inflicted by the 1918
Spanish flu, public perceptions regarding the danger posed by the disease shifted
markedly. For a time influenza became known as a ‘war disease’ (Francis 1947, 10),
prompting the US military in 1941 to establish the Armed Forces Epidemiological Board
to undertake research and development into influenza vaccines even as World War II
raged in Europe (Hoyt 2006). These efforts were replicated across a variety of countries,
including the Soviet Union, the United Kingdom, Australia, Argentina, and Canada,
amongst others (Watterson and Kamradt-Scott 2016). In the wake of World War II,
work on influenza vaccines shifted to the civilian sector, concentrated in a small number
of high-income countries. Concern about a repeat of what had happened in 1918 never-
theless remained high, and in 1946, when the decision was taken to establish a new
universal health agency in the form of the World Health Organization, one of the first
tasks assigned to the Interim Commission of the WHO was to institute a new pro-
gramme to monitor and study the virus.
 Politics of Pandemic Influenza Preparedness   533

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

gathered from these campaigns definitively revealed the utility of vaccination, and since
then vaccination has become recognised as the cornerstone of pandemic preparedness.
To that end, the GISN increasingly began to share the data it gathered on circulating
viral strains with pharmaceutical manufacturers to facilitate the production of influenza
vaccines. This strategy proved particularly beneficial when the Hong Kong flu pandemic
commenced in 1968.
The 1968 influenza pandemic reportedly again began in China, but given that external
relations with the Communist state had deteriorated even further since the late 1950s,
the virus was not detected until it reached Hong Kong and Singapore (Kilbourne 2006;
Quinn 2008). From Hong Kong the virus then continued to spread around Asia before
being carried to the United States by US Marines returning from Vietnam. By the winter
of 1968–1969 it had spread to Europe (Tagnotti 2013). The WHO officially notified gov-
ernments that a pandemic was under way on August 16, 1968, and by mid-September—
based on the experience of the 1957 pandemic—laboratories in the United States started
work on developing a new pandemic-specific vaccine. Vaccination campaigns were
then able to officially commence just two months later, on November 19, though the
virus ‘had largely spent itself [in the United States] by the end of 1968’ (Hillman 1969,
623). This reportedly resulted in less domestic uptake of the vaccine, but the upshot of
less interest in vaccination by US citizens was that the vaccines were then available to be
utilised in parts of Europe and the Southern Hemisphere, where the pandemic was still
unfolding (Hillman 1969).
The collective experience of both the 1957 and 1968 pandemics conclusively revealed
that influenza vaccines were effective in reducing human morbidity and mortality. As a
result, a number of governments in high-income countries (HICs)—where the majority
of vaccine manufacturers were located—focused their efforts over the next few decades
on ensuring greater vaccine yield in faster time frames (Kamradt-Scott 2013). Increased
recognition of the utility of antiviral medications as a second line of defense added to
the influenza pharmaceutical ‘arsenal’ (Glezen 1996; Mendel and Sidwell 1998), but the
ability to produce pandemic-specific influenza vaccines—which, crucially, relied on
seasonal influenza vaccine manufacturing capacity—remained the core capability that
many Western governments were keen to maintain.
Importantly, however, the apparent success of influenza vaccines in reducing human
sickness and death had an unanticipated and converse impact on international pandemic
preparedness policy and practise. For decades the primary concern driving inter-
national collaboration had been the possibility that the 1918 Spanish flu pandemic would
be repeated. Whilst a number of influenza experts periodically attempted to highlight
the ongoing hazard of an influenza pandemic (WHO 1988; Webster 1994), for most
HICs that maintained influenza vaccine manufacturing capacity, the risk of 1918 being
revisited perceptibly lessened. Instead, throughout the latter half of the twentieth century
influenza became increasingly viewed as a controllable disease that was most appropri-
ately addressed by individual governments, ideally through vaccination campaigns
that had been verified by biomedical knowledge and techniques such as clinical trials
(Hota and McGeer 2007). The consequence of the lack of interest in collective action
 Politics of Pandemic Influenza Preparedness   535

approaches by wealthier governments was a concomitant reduction in influenza-related

funding. Disturbingly, this culminated in a situation in which when the 1997 outbreak
of H5N1 influenza occurred in Hong Kong, reigniting fears that another influenza pan-
demic was imminent, the influenza division of the WHO had been reduced to just one
full-time staff member (Kamradt-Scott 2012).

A New Era of Awareness

and Vigilance

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

the advice of key global governance institutions, many governments sought to protect
their populations through stockpiling antiviral medications and gaining access to influ-
enza vaccines.
Perversely, the demand for H5N1 influenza vaccines grew to such an extent that it
inadvertently fractured the WHO’s GISN. Confronted with a growing number of H5N1-
related cases, in 2006 Indonesia’s president authorised the then health minister, Siti
Fadilah Supari, to purchase a stockpile of H5N1-specific vaccines. Whilst several
pharmaceutical manufacturers indicated they would be prepared to sign an advance
­purchase agreement (APA) with the Indonesian government to supply the requested
vaccines, they also indicated that Indonesia would only receive its vaccines after other
APA agreements had been filled (Kamradt-Scott and Lee 2011). Since Indonesia was the
country with the highest number of H5N1-related fatalities, this response understand-
ably infuriated the Indonesian authorities. When several related infringements related
to the GISN’s virus-sharing arrangements also came to light, Supari announced in
January 2007 that Indonesia would cease sharing samples of the H5N1 virus with the
WHO’s GISN, claiming ‘viral sovereignty’ (Sedyaningsih et al. 2008).
Indonesia’s controversial decision was condemned by some as effectively holding the
world to ransom (Fidler 2008), but it garnered support from several other low-income
countries (LICs) that also were struggling to access vaccine stocks (Fedson 2009).
Indeed, whilst Indonesia was the only country to publicly announce it had ceased sharing
influenza virus samples, and commentators concluded Supari’s decision was possibly
motivated more by domestic political ambitions (Hameiri 2014), a number of countries
reportedly considered following Indonesia’s lead. In response, the WHO convened a
series of intergovernmental sessions throughout 2007 and 2008 in an attempt to find a
diplomatic solution. When the initial meetings failed to arrive at a consensus, a more
formal intergovernmental open-ended working group (OEWG) was established.
Between 2010 and 2011 the OEWG met formally three times in addition to holding a ser-
ies of consultation meetings with civil society organisations. Concurrent with these
meetings, Indonesia pursued its claims of ‘viral sovereignty’ through the Convention on
Biological Diversity conference in an attempt to strengthen its negotiating position
within the OEWG meetings. In May 2011 the 64th WHA endorsed a new agreement—
the 2011 Pandemic Influenza Preparedness Framework (PIPF) (Krishnamurthy and
Herder 2013).
The 2011 PIPF has substantially altered the nature of the WHO’s GISN, transforming
it from a network exclusively funded by governments into a new public-private partner-
ship. The GISN has also been renamed the Global Influenza Surveillance and Response
System, or GISRS. Under the new agreement pharmaceutical manufacturers are no
­longer permitted to access data and biological samples on circulating virus strains to
develop influenza vaccines without committing to ‘benefit-sharing’ arrangements that
include, for instance, providing a percentage of influenza vaccines at heavily discounted
prices. Other ‘benefits’ include such measures as technology transfers and improved
access to diagnostic reagents and influenza test kits—resources that many LICs previ-
ously struggled to obtain. Pharmaceutical companies that seek to access the data and
 Politics of Pandemic Influenza Preparedness   537

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

respiratory diseases be heightened, and over the first ten days in April nongovernmental
and government-based agencies reported an outbreak of influenza-like illness in La
Gloria, Veracruz, that had reportedly affected a large proportion of the local inhabitants
(WHO 2009a; Brown 2009; Shkabatur 2011). Under a trilateral agreement amongst the
United States, Mexico, and Canada, clinical specimens collected from patients were sent
to the US Centers for Disease Control and Prevention (CDC) in Atlanta and the
National Microbiology Laboratory of the Public Health Agency of Canada for testing.
Confirmation that these samples were of a novel strain of influenza A (H1N1) came in
late April, but by this time the virus had not only spread to Mexico City but also inter-
nationally to the United States and Canada (WHO 2009a). By June 1, 2009, the WHO
had received confirmed reports of H1N1 cases in sixty-four countries, prompting the
organisation to officially declare on June 11, 2009, the first pandemic of the twenty-first
century (WHO 2009b).
Compared to previous pandemics, the severity of the 2009 H1N1 influenza pandemic
initially appeared far less significant, provoking questions about whether the WHO had
been unduly influenced to declare a pandemic. Three investigations—two external and
one internal—were subsequently launched into the WHO’s decision-making processes
and response, but in handing down their findings all three concluded that the WHO had
not been pressured into making its determination. When the WHO director general
officially declared the pandemic over on August 10, 2010, a total of 18,449 fatalities had
been formally attributed to the H1N1 virus (WHO 2010). It was later estimated, however,
that the number of deaths directly attributable to the virus globally was more likely
between 123,000 and 203,000, and that the number of deaths arising from H1N1-related
complications increased the overall human morbidity to 400,000 (Simonsen et al. 2013).
Whilst the 2009 H1N1 virus was thus far less virulent than pandemics of the twentieth
century, it nonetheless proved to be a significant global event and worthy of the WHO’s
description of a ‘pandemic’.
In the aftermath of the 2009 H1N1 pandemic, the wider international community was
beset by what has been described as ‘pandemic fatigue’. This ‘fatigue’, which refers to a
generalised reluctance to even discuss pandemic-related issues or topics (Dumiak 2012),
persisted for several years and was compounded by the 2008 financial crisis, which dis-
couraged further investment in pandemic preparedness (Brahmbhatt and Jonas 2015).
As a phenomenon, however, it proved particularly problematic, given that in the wake of
the H1N1 pandemic, several recommendations for reforming the WHO and creating
new rapid response mechanisms for responding to health crises had been ignored—
mechanisms that in the wake of the 2014 West African Ebola outbreak were re-examined,
endorsed, and finally, actioned (McInnes 2015; Gostin et al. 2016). In implementing
these reforms, however, pandemic preparedness has been increasingly devolved from
the WHO to include other global actors not traditionally associated with health, let
alone pandemic influenza preparedness.
Indeed, since 2005 several prominent institutions and actors, such as the IMF, the
World Bank, UNICEF, and more recently the Gates Foundation, have been actively
engaged in strengthening global pandemic preparedness. The form of these institutions’
 Politics of Pandemic Influenza Preparedness   539

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

The Norms and Ideas Shaping

Pandemic Policy

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

driving forward not only influenza-related science but also policy decisions aimed at
preventing a repeat.
Within this historical context the primary focus has been on averting excessive
human morbidity and mortality. Given that seasonal influenza epidemics generally
result in a small proportion of lives lost, most medical professionals (and therefore
policymakers) accept that the disease will kill some people despite their best efforts
(Graham-Rowe 2011). In most HICs, however, since the 1950s and the discovery of the
efficacy of influenza vaccines, considerable emphasis has been placed on vaccinating
the most vulnerable population groups, traditionally those immunocompromised
individuals at either end of the life spectrum. Biomedical knowledge, techniques, and
technologies have thus remained central to influenza-related policy since the early
twentieth century, and the influence of biomedicine in shaping pandemic preparedness
policy has continued to grow and solidify over time. Even so, as highlighted later in this
article, the field has also been extensively shaped by a variety of other competing ideas
and normative agendas, resulting in political contestation over the most appropriate
way to deal with the issue.
Prior to discussing the norms and ideas that have shaped pandemic policy over the
past century, it is important to note a particular feature that has customarily informed
pandemic planning and preparedness policy, one that has now been potentially invali-
dated. As noted previously, the 1918 pandemic resulted in an overall global case fatality
ratio of approximately 2.5 percent. This meant that the vast majority of people infected
with the Spanish flu virus went on to make a full recovery. Yet in subsequent pandemic
planning and preparedness decision-making, it has often been assumed that in order
for an influenza virus to achieve effective human-to-human transmission—thereby cre-
ating the potential for a pandemic—the virulence of the virus would diminish to the
extent that the case fatality ratio would not exceed that of the 1918 Spanish flu virus
(Morens et al. 2010). Put another way, public health professionals and pandemic pol-
icymakers have traditionally viewed the 1918 Spanish flu pandemic as the ‘worst case
scenario’ that they need to prepare for (Moxnes and Albert Christophensen 2008).
In 2011 experiments conducted by two distinct groups of scientists who manipulated
the H5N1 avian influenza virus raised the possibility that an airborne strain of influenza
could emerge naturally that may infect humans and retain its current case fatality ratio
in excess of 50 percent (Herfst et al. 2012; Imai et al. 2012). Whilst controversy raged over
whether the scientists should have been permitted to conduct and then publish their
research (Herfst, Osterhaus, and Fouchier 2012), the arguably more important discovery
that an influenza pandemic capable of killing more than 2.5 percent of those infected
worldwide could emerge naturally—and the existential threat that virus represents—
has yet to sufficiently permeate international preparedness and planning. The cata-
strophic nature of such a development defies all contemporary planning scenarios,
including those of the WHO and of countries with the most advanced healthcare
­systems (e.g., WHO 2017b). Although this research arguably warrants further attention
and consideration by policymakers, historically other issues have dominated the influ-
enza policy sphere.
 Politics of Pandemic Influenza Preparedness   541

As previously noted, the centrality of biomedical knowledge, techniques, processes,

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

these pharmaceutical interventions, which had been validated through EBM-related

techniques, was further manifested when it was revealed that of the estimated US$1.48
billion needed to support the ninety-five least-resourced countries to respond adequately
to the H1N1 pandemic, some US$1.14 billion (77 percent) was allocated to purchasing
‘H1N1 vaccines and other medicines’ (UNSIC and World Bank 2010, 30).
As a method that advances apolitical ‘objective’ data, EBM has become so compelling
that other fields have sought to either co-opt its techniques or emphasise their own cap-
abilities in generating equivalent statistical data, to gain comparable political influence
in shaping policy decisions. For example, even at the launch of the World Influenza
Centre in 1947, it was recognised that influenza pandemics could have a devastating
impact on not only national economies but also international trade. In this regard, the
economic consequences of a widespread influenza pandemic have long been recognised.
Especially since the late 1990s, however, a series of econometric studies examining the
potential impacts on national productivity, social cohesiveness, and economic function-
ing have increasingly been used to evaluate mitigation strategies (such as vaccination
programmes), justify policy decisions, and further emphasise the need for pandemic
planning (Meltzer et al. 1999; Gust et al. 2001). As time passed, various government
bodies increasingly combined EBM and economic analyses—such as ‘cost-benefit
analysis’ techniques—in determining their planning and policy priorities for influenza
(Nichol 2001; Belsey 2009). Similar arguments have been used to justify the creation of
the World Bank’s new Pandemic Emergency Financing Facility, which aims to help
countries become ‘better prepared for and able to respond to pandemics as well as [the
international community’s] ability to handle the next pandemic on a global level,’
largely through offsetting the economic losses that would otherwise ensue (World
Bank 2017). This trend has continued to such an extent that especially when it comes
to pandemic influenza preparedness policy, EBM and econometrics are often now
inseparably entwined.
Indeed, it has now become commonplace to fuse cost-benefit analyses with
­evidence-based medical interventions to rationalise pandemic-related policies. Studies
are now habitually produced that use mathematical modeling and statistical inference
to scrutinise pandemic influenza prevention and containment strategies and also draw
on evidence-based data of specific medical interventions (e.g., vaccination, stockpiling
antiviral medications) to justify or invalidate particular policy decisions (Ferguson
et al. 2006). Whilst attention has often focused on pharmaceutical-based interventions
that can be more readily quantified through EBM techniques such as RCTs (Balicer
et al. 2005), these same strategies have been expanded recently in an attempt to quantify
nonpharmaceutical or social-distancing measures such as school closures, measures
that historically have been characterised by a ‘lack of evidence’ (Cauchemez et al. 2009,
473). The extension of these methods thus represents a new phase in evidence-based
decision-making whereby a combination of ideas is used strategically to determine
­policy directions.
A third and closely aligned concept that has become increasingly observable in pan-
demic influenza preparedness policy has been ‘security’. As previously noted, for a time
 Politics of Pandemic Influenza Preparedness   543

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

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

Conclusion

It is a common refrain amongst public health professionals and policymakers that

another influenza pandemic ‘is not a matter of if, but when’. Even with tremendous
medical advances, the creation of a dedicated international surveillance network, and
quadrupling global vaccine manufacturing capacity since the start of the new millennium,
the menace of another influenza pandemic wreaking widespread human suffering and
severe economic disruption remains. This is principally because the influenza virus is
prone to mutation, and the ease with which the virus moves amongst a number of spe-
cies makes it a poor candidate for global eradication. Since the late 1950s the best defence
 Politics of Pandemic Influenza Preparedness   545

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

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 chapter 28

The Gl oba l Politics

of HI V a n d A IDS

Alan Whiteside

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

The first AIDS cases were publicly reported in 1983, and the viral cause was isolated in
1983. In 1987 the name human immunodeficiency virus was confirmed. The current
generally accepted term is ‘HIV and AIDS’ to distinguish between the periods when a
person is infected and when he or she is ill. Treatment can mean a person will not pro-
gress beyond being HIV infected and so would never fall into the ‘AIDS’ category. At the
time of publication (2017) there is still no cure for AIDS, and once people are HIV
infected, they will remain so for the rest of their lives. Science has made huge progress,
and infection is no longer a ‘death sentence’; people can be treated and live close to
­normal lives provided they adhere to the drugs. However, this has an economic and
­psychological price.
One other point is to locate HIV and AIDS in public health thinking, as ultimately the
epidemic is a public health issue. This fact was excellently captured in Davies et al. (2014),
which identified four historical waves of public health development and which in turn
helps us to understand the public health approaches to HIV and AIDS. The first wave
(1830 to 1900) was structural: addressing physical and environmental conditions, ensur-
ing clean water and sewerage disposal, legislating for food safety, and improved working
conditions. The second wave (1890 to 1950) was biomedical and scientific advances: the
first vaccine (smallpox) administered in 1796 and the United Kingdom’s 1853 Vaccination
Act, which made immunization for smallpox compulsory for infants by the age of three
months. By the end of the last century vaccines were lowering morbidity and mortality,
especially among children. This was one of the reasons for the misguided optimism that
an HIV vaccine would be quickly developed.
The third wave (1940 to 1980) was clinical and scientific. There was understanding of
causes of disease, and treatments were developed. Alexander Fleming identified the first
antibacterial medicine, penicillin, in 1928. There were significant discoveries of new
drugs of different classes for management of bacterial and viral infections. Rapid
advances in cancer treatment included drugs, radiation, and surgery. The fourth wave
began in 1960 with examination of the social determinants of health, and understanding
ill health generally has roots in economic and social factors. In 2005 the World Health
Organization (WHO) established the Commission on Social Determinants of Health
(CSDH) to address the social factors leading to ill health and health inequities. Its report
was issued in July 2008. It implicitly built on the work of Freire, Illich, and Wilkinson.2
Most recently, Angus Deaton has pioneered new directions of thinking, especially with
regard to equity (Deaton 2013). Ultimately the spread of HIV has its roots in economic
and social determinants, including poverty, gendered dimensions of disease, and
inequality. Davies and colleagues (2014) argue that the fifth wave will be ‘a culture for
health’. In this environment health should be the norm, it should be valued and incentiv-
ized, healthy choices should be the default, and unhealthy activities should be actively
discouraged. This might have application in the rich world; it is less clear how people in
developing nations will be able to respond. If the culture for health becomes the norm, it
will have far-reaching implications for the culture of global health.
Health is not simply a technical subject, and the history of and response to AIDS show
this clearly. We have evidence and interventions, but putting them in place requires
 Global Politics of HIV and AIDS   553

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

The Emergence of AIDS

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

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

The Politics of Blame

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

The First Fifteen Years: 1981 to 1996

The initial response followed standard public health patterns. Once the routes of
transmission—blood, blood products, and body fluids—had been identified as sources
­
 Global Politics of HIV and AIDS   555

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

established in 1986, included condom promotion, sentinel surveillance to determine the

scope of the epidemic, confidential counseling and testing, education of sex workers,
and integration of HIV into sex education. Its effectiveness was marked by involvement
of religious and community leaders, including a partnership between healthcare
­providers and Muslim and Christian religious leaders.
In the three countries cited above (and the developed world), political leaders recog-
nized the threat to their people and societies and were able to grasp the nettle of dealing
with a sexually transmitted disease. They were, however, the exceptions. Most resource
poor countries relied on support from WHO’s Global Programme on AIDS, which
mobilized ‘swat teams’ of doctors, epidemiologists, and health educators who came in
for short periods, establishing short term programmes (STPs) and then medium term
programmes (MTPs). This was in part because ministries of health were stretched, but
perhaps more important, the epidemic was invisible; although HIV infections were
spreading rapidly, there were few AIDS cases.
In the West AIDS was politicized from the beginning. The gay populations were
motivated, active, and organized. At the Third International AIDS Conference in
Washington in 1987, there were demonstrations against the lack of political commit-
ment, the slow processes in developing and approving treatment, and the reluctance of
President Ronald Reagan to talk about or even acknowledge the existence of the epi-
demic. Even when Reagan mentioned HIV, he did not acknowledge the vulnerability of
the gay population. The US government banned HIV-positive travelers from entering
the country, citing both public health concerns and the potential financial burden on US
health services. As a result the AIDS 1992 conference was moved from Boston to
Amsterdam. This politicization, however, was successful because it meant that in gen-
eral the best (albeit very limited) treatments were made available, there were continued
prevention campaigns, and the disease remained high on the agenda. Some global opin-
ion leaders were also quick to address the stigma associated with being HIV positive.
Most notably, in 1987 Princess Diana was photographed shaking hands with an HIV
positive man, although even then the photographer was asked not to show the man’s
face lest he be stigmatized.
The UNAIDS and WHO developed four epidemiological scenarios:

• Low-level: HIV has not spread to significant levels in any subpopulation because
networks of risk are diffuse. This is the entire developed world.
• Concentrated: prevalence is high enough in one or more subpopulations, such as
MSMs, (IDUs, and sex workers and clients, to maintain the epidemic, but the virus
is not circulating in the general population. This includes parts of Asia, Eastern
Europe, Latin America, the Middle East, and the Caribbean.
• Generalized: HIV prevalence is 1–5 percent in pregnant women attending antenatal
clinics. The presence of HIV among the general population is sufficient for sexual
networking to drive the epidemic. In an epidemic with more than 5 percent adult
prevalence, no sexually active person is ‘low risk’. The areas affected are parts of
Africa and the Caribbean.
 Global Politics of HIV and AIDS   557

• Hyper-endemic: HIV is above 15 percent in adults in the general population. There

are extensive heterosexual, multiple concurrent partner relations with low and
inconsistent condom use. All sexually active persons are at risk. The drivers include
early sexual debut, multiple concurrent sexual partnerships, intergenerational sex,
low acceptability of condom use, and biological cofactors such as low levels of
male circumcision and the presence of sexually transmitted infections. There may
be high levels of HIV-related stigma; gender-based violence, including sexual coer-
cion; and gender inequality. This pattern is seen in eastern and southern Africa.

AIDS Comes of Age: 1996 to 2010

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

and counseling for troops deployed in peacekeeping. However, it stated that the spread
of HIV and AIDS could have a ‘uniquely devastating impact’ on all sectors and levels of
society and pose a risk to stability and security. At the meeting Peter Piot, the director of
UNAIDS, said that ‘beating back the epidemic in Africa alone would cost $3 billion’ (UN
2000). AIDS had come of age: the first disease to be given this level of attention, being
debated in the Security Council and resulting in specific resolution.
Following the Security Council’s deliberations, there was a period of intense analysis
of the potential disruptive impact of the epidemic. This was seen in the work of the US
Bureau of the Census in particular, which produced extremely pessimistic population
projections (US Bureau of the Census 2004). In addition, there was academic analysis.
My early engagement with the epidemic meant I was among the first to write, admit-
tedly speculatively, on the possible impact (e.g., Whiteside and FitzSimmons 1992).
The bulk of the work on potential impacts, however, emerged in the 2000s. In hind-
sight it is apparent that HIV was not, as feared, a significant security or economic risk,
although for infected individuals and their families, it remains devastating. Reasons for
this ‘overstatement’ of potential impact were the lack of treatment, cost of drugs (which
it was believed would remain prohibitively high), and apparently unstoppable spread of
the virus in southern Africa. The theme of the 2000 International AIDS Conference,
held in Durban, was ‘Breaking the Silence’. The silence identified by the organizers was
around access to treatment and prevention and human rights. Despite progress, stigma
and economic constraints remained. As it happened, but was not foreseen at the time
the slogan was adopted, the political atmosphere was highly charged. South Africa was
entering its ‘denial period’, in which President Thabo Mbeki argued, confusedly, that
HIV did not exist, but if it did then it was not a killer virus, and (anyway) ARV treat-
ments were ineffective and toxic. These attitudes were greeted with disbelief by most
scientists and health professionals, as well as some senior government and political fig-
ures.4 Observers have not definitively understood the underlying issues that led to
Mbeki taking this stance; it may have been caused by the stigma of a sexually transmit-
ted disease, irritation about Afro-pessimism, or personal issues. Unfortunately, in 2016
Mbeki reiterated his statements, asking why the virus behaved differently in Africa and
the West and arguing that poverty and nutrition were critical (Mbeki 2016). This is
analogous to trying to decide if the house was set on fire with matches or a lighter rather
than dousing the flames.
In 2002 research conducted by Tony Barnett and myself was published that intro-
duced the ‘Jaipur paradigm’ (because the ideas emerged in a workshop in Jaipur in
India), which explained some of the social factors influencing the spread of the disease.
(Barnett and Whiteside 2002). The extent of the progression of the AIDS epidemic was
at that time becoming apparent. It was clear that in some countries the focus of the dis-
ease would be among specific risk groups, while in others there was a generalized epi-
demic with exceptionally high levels of infection. Working with numerous international
academic participants, development agencies, and others, we tried to understand why
the epidemic was so bad in some areas and not others and if in turn this could be pre-
dicted. We had to understand the social and economic processes driving the epidemics
 Global Politics of HIV and AIDS   559

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

The early years of the new millennium also saw the creation of two major initiatives to
respond to the epidemic. First, following the January 2000 UN Security Council meeting,
Secretary-General Kofi Annan called for the creation of a ‘global war chest’ to finance
Millennium Development Goal (MDG) 6, which was to combat AIDS, tuberculosis,
and malaria. As a result, in January 2002 the Global Fund to Fight AIDS, Tuberculosis
and Malaria (GFATM) opened for business in Geneva with the clarion cry ‘Raise it,
Spend it, Prove it’. Second, in 2003 Republican president George W. Bush pledged US$15
billion in establishing the President’s Emergency Plan for AIDS Relief (PEPFAR).
Activists were surprised and delighted by the action of a conservative Republican presi-
dent. In 2015 Bush said: ‘As President I found it morally unacceptable for the United
States to stand aside while millions of people died from a disease we could treat. I also
recognized that saving lives in Africa serves America’s strategic interests. When soci-
eties abroad are healthier and more prosperous they are more stable and secure’ (Bush
2015). PEPFAR has been reauthorized every five years since then.
Concern about the epidemic in Africa also led Kofi Annan to convene, in 2003, the
Commission on HIV/AIDS and Governance in Africa (CHGA) under the leadership of
K. Y. Amoako, the executive secretary of the United Nations Economic Commission for
Africa (ECA). I was a member of this commission, which reported in 2006. Our man-
date was to

(i) clarify the data on the impact of HIV/AIDS on state structures and economic
development; and
(ii) assist governments in consolidating the design and implementation of policies
and programs that can help to govern the epidemic.

It was clear from these deliberations that while resources were necessary, there needed
to be national and international leadership. Nevertheless, during the early years of the
new millennium the money flowed into HIV and AIDS, as shown in Figure 28.1. One of
the key issues to which the chapter will return is future sources of funding. The political
economy of the epidemic was neglected in times of plenty, when the challenge was how
to spend resources rather than raise them. The financial crisis in 2008 led to a brief plat-
eauing of funding, but soon it trended upward again.
Although the SARS outbreak in 2002–2003 had demonstrated the potential of a pan-
demic to spread internationally (but fortunately it was brought under control), and an
easily transmitted flu variant based on H5N1 (‘avian flu’) became a significant preoccu-
pation during the first decade of the new millennium, AIDS remained the primary per-
ceived infectious disease threat to the world until the Ebola outbreak, which began in
March 2014 in West Africa. These diseases have shown global health is not as robust as
was previously thought (and hoped). Ironically, the experience of the AIDS epidemic
has been valuable in addressing the new challenges. It has helped in tracking and under-
standing the spread of disease, putting in place the science for prevention, and develop-
ing potential treatments and ultimately, cures.
 Global Politics of HIV and AIDS   561

$25
US$ 21.7 billion

$20

Global financial crisis

$15 UN Political Declaration

US$ Billions

on HIV/AIDS

UN High-level Political
Declaration on HIV/AIDS
$10

High-level Declaration of
Committment
$5 Beginning of Millenium
Development Goals
UNAIDS PEPFAR established
established Global Fund established
$-
96

97

98

99

00

01

02

03

04

05

06

07

08

09

10

11

12

13

14

15
19

19

19

19

20

20

20

20

20

20

20

20

20

20

20

20

20

20

20

20
Figure 28.1 Global funding for HIV and AIDS.
Reproduced from Whiteside, Alan. HIV & AIDS: A Very Short Introduction. 2nd ed. New York: Oxford University Press, 2017.
Source: Based on data taken from ‘No Money, No Results! New Estimates of Need,’ by Carlos Avila and Catherine
Hankins, Joint United Nations Programme, with permission, and Kates et al., ‘Financing the Response to HIV in
Low- and Middle-Income Countries: International Assistance from Donor Governments in 2012’ (The
Henry J. Kaiser Family Foundation, September 2013), http://www.unaids.org/sites/default/files/en/media/unaids/
contentassets/documents/document/2013/09/20130923_KFF_UNAIDS_Financing.pdf.

The New Challenges:

2010 to 2017 and Beyond

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

range of other interventions that are tried and tested means of reducing likely exposure,
including delaying sexual debut, sticking to one partner, using sterile needles in the case
of IDUs, and using barrier methods to make sex safer (the condom is one of the best, and
although female condoms have been developed, they are generally not popular).
Medical male circumcision reduces the likelihood of infection for the man by about 60
percent, while the need for female-controlled methods resulted in the development of
microbicides.5
The gendered nature of the epidemic has long been understood. Women are more
likely to be infected than men. The female risk in receptive penile-vaginal intercourse is
8 per 10,000 exposures; for men with insertive penile-vaginal intercourse the risk is 4
per 10,000 exposures. Women face violence and a lack of empowerment when it comes
to controlling sex. They are also the primary caregivers for the sick.
In the past treatment was advocated for people with a CD4 count below a certain
level: initially 200, then 350, then 500 cells/mm3. Most recently it has been established
that a person on ART is up to 96 percent less likely to transmit HIV. This has led to a
push to identify all infected people and put them on treatment as soon as possible. This
new intervention is known as treatment-as-prevention (TasP). The International AIDS
Conference held in Durban in 2016, however, sounded a note of caution about this
approach (Iwuji et al. 2016). A study called ANRS12249 used the ‘test and treat’ strategy
of testing people and offering ART immediately to those who were infected. It was
expected and hoped that infected people would start taking drugs as soon as they
learned they had HIV. The study found that only 47.5 percent of those infected sought
care within the first six months of learning their status. Clearly more thought needs to
go into treatment as prevention, as people have to be on therapy before their viral loads
will fall.
The idea of pre-exposure prophylaxis (PrEP) will be intensely debated over the next
five years. If an uninfected individual takes the drugs, he or she will be protected from
HIV transmission if a partner is infected. However, PrEP is not cheap—it can cost up to
$13,000 per year—and one of the questions is who should pay for it (PrEP Facts 2016).
The cost-benefit analysis economists do suggests that even if the infrastructure were in
place, this is not a viable option for most countries, but there might be an argument for
providing it for specific high-risk groups such as sex workers. This is a potential political
minefield in rich countries and is unlikely to even be on the agenda elsewhere.
In their recent discussion of the ethics of expanding access to cheaper, less-effective
treatments, Persad and Emanual (2016) indirectly address these issues. They quote
WHO director Gro Harlem Brundtland’s statement: ‘If services are to be provided for all
then not all services can be provided. The most cost-effective services should be pro-
vided first’. They also note that provision of less-effective or more toxic interventions
should be justified by the principles of utility, equality, and priority for those who are
worst off. ‘Advocates and WHO are mistaken to demand that medical care provided in
low-income and middle-income countries should be the same as in high-income coun-
tries. Instead, expansion of access to treatments that are effective, even if not the most
effective, should be the standard in global health’ (Persad and Emanuel 2016, 933).
 Global Politics of HIV and AIDS   563

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

provide a steady, sustainable and equitable way of generating small amounts of

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

Conclusion

When looking at disease it is evident that wealth is one of the key determinants of peo-
ple’s relative health. The classic study of civil servants in the United Kingdom showed
that the higher ranks lived longer, healthier lives than their more junior colleagues
(Marmot et al. 1978). This is part of the picture. The other is the issue of equality and how
the society functions. The ‘World Happiness Report Update’ shows that the happiest five
countries in the world are, in order, Denmark, Switzerland, Iceland, Norway and
Finland (Helliwell, Huang, and Wang 2016). The countries with the worst epidemics fall
in the last third of the list of 150. The economics of health—both causes and ‘cures’—
should correctly be understood as political economics.
By the turn of the millennium, it was believed that AIDS could have significant polit-
ical impacts because of both the costs and who would be affected. It was believed there
would be significant loss of leaders and voters, changing voting patterns, and disengage-
ment and disillusionment with the political process at all levels. Moreover, in the early
years of the epidemic there was evidence of increased mortality among politicians. The
availability of ART changed this, and it is not surprising that politicians are among the
first to access treatment. It is now clear that potential political impact is more limited.
The Democracy in Africa Research Unit (DARU) at the University of Cape Town collab-
orates with the University of Michigan on the Afro-barometer project, which meas-
ures the social, political, and economic atmosphere through national public attitude
surveys. These show that HIV and AIDS are not important as political or election issues.
People’s primary problems are unemployment and poverty. In the first round of surveys,
AIDS featured on the public agenda of only three southern African countries: 24 per-
cent of Botswanans, 14 percent of Namibians, and 13 percent of South Africans cited
HIV/AIDS as one of the top three problems facing the country. The question posed sub-
sequently was: ‘In your opinion, what are the most important problems facing this coun-
try that government should address?’ Only in Botswana was AIDS seen as a significant
 Global Politics of HIV and AIDS   565

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

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

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 chapter 29

The Gl oba l Politics

of N egl ected
Tropica l Dise ase s

Obijiofor Aginam

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

Neglected tropical diseases (NTDs), according to the World Health Organization

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

Gorrie 2005). Juxtaposed with comparable disparities between and amongst countries
in the development discourse, Falk (1999, 13, 17) deployed the metaphor of ‘global apart-
heid’ to argue provocatively that:

Several characteristics of the global political economy shape the tactics and aspirations
of progressive social forces: extreme hierarchy and unevenness of circumstances,
acute deprivation and mass misery amongst the poor; erosion of autonomy at the
level of the state as a consequence of the play of non-territorial capital forces. . . . If
these critical differences are appreciated, the global apartheid metaphor seems use-
ful. It confronts the moral and political complacency of the North. . . . The metaphor
of global apartheid, then, represents a warning as well as a provocative line of cri-
tique, suggesting the urgency of taking far more serious steps to overcome the
North-South cleavage.

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

Fatal Imbalance: NTDs and

the 10/90 Divide

Global health scholarship is replete with literature on the ‘fatal imbalance’ between the
health of the rich and poor across societies (Baxi 2010; Farmer 2001, 2005; Garrett 2000;
Pogge 2002; Labonte et al. 2004; WHO 2001b). As Orbinski (2008, 366) argued, a fatal
 Global Politics of Neglected Tropical Diseases   571

imbalance has always ‘existed between the health needs of poor people in developing
countries and the lack of R&D to develop medicines to treat them’. In 2000 the Global
Forum for Health Research published the widely cited 10/90 Report, which deplored the
imbalance in global health research that largely ignored NTDs (Global Forum for
Health Research 2000). Economic and financial incentives driven by profit maximisa-
tion have historically been the major motivation behind the R&D budget in the global
pharmaceutical industry (‘t Hoen 2009; Santoro and Gorrie 2005). As Callahan &
Wasunna (2006, p.192) observed:

The much cited “10/90 divide”—with 90 percent of medical research going towards
diseases for just 10 percent of the world population—shows the gross neglect of
research for diseases afflicting the world’s majority poor. . . . The bottom line is that
the developing world does not represent a profitable market for the international
pharmaceutical industry. In effect, the industry is saying that, because of an inability
to pay for them, or to properly distribute and monitor them, development of drugs
for the diseases of poor countries is a financial loser.

The 10/90 gap in health-related R&D means that ‘many diseases that occur largely in the
developing world amongst poor people are neglected and thus the diseases themselves
thrive. Because of a virtual absence of drug R&D, millions continue to suffer and die
from diseases such as malaria, TB, sleeping sickness (trypanosomiasis), Chagas disease,
or leishmaniasis’ (Orbinski 2007, 33).
The neglect of NTDs—as diseases of the poor—has led to their glaring invisibility in
international development policy frameworks. NTDs were largely invisible in the
Millennium Development Goals (MDGs), packaged to target socioeconomic issues
affecting the poor. In the MDGs, NTDs were packaged amongst ‘other diseases’ without
any express mention (Furst et al. 2017). In their concise historical overview of NTDs
in global health policy, Furst et al. (2017) observed that the omission of NTDs in the
MDGs was a

[c]all to arms for the NTD stakeholders and a stimulus to join forces to gain a crit-
ical mass. Key arguments were the considerable geographical overlap of NTDs, the
commonness of co-infections related to shared risk factors, their poverty-driven
and poverty-promoting characteristics, and potential synergies in fighting them.
The little resources devoted to NTDs in relation to their burden and the availability
of comparatively cheap options for treatment and prevention further encouraged
the coordination of specific efforts to address the NTDs and to develop the NTD
brand.

The fifteen-year lifespan of the MDGs (2000–2015) substantially overlapped with

WHO’s Global Plan to Combat Neglected Tropical Diseases 2008–2015. To what extent
did the WHO Plan align with NTD stakeholders locally and globally to develop an
innovative NTD brand?
572   Obijiofor Aginam

WHO’s Global Plan to

Combat Neglected Tropical
Diseases, 2008–2015

Adopted in 2007, the Global Plan was an ambitious policy framework to combat NTDs
based on the vision that ‘NTDs and zoonoses are a devastating obstacle to human settle-
ment and socioeconomic development of already impoverished communities’
(WHO 2007). The goal of the Global Plan was to ‘prevent, control, eliminate and eradi-
cate NTDs and zoonoses’ by providing measures for the ‘prevention, early detection,
diagnosis, treatment, control, elimination and eradication of NTDs and zoonoses that
disproportionately affect poor and marginalised populations’ (WHO 2007). Anchored
on several core public health principles, including the right to health enshrined in the
WHO Constitution (WHO 2001a, 1)—‘the enjoyment of the highest attainable standard
of health’ by every human being”—the Global Plan laid out nine strategic areas for
action, including the urgent need for ‘partnerships and resource mobilisation’ (WHO
2007). Assessing the implementation of the Global Plan, it is arguable that whilst WHO
may have succeeded in articulating the key challenges in NTD control, the organisation
failed in its efforts to catalyse innovative partnerships to incentivise the pharmaceutical
industry towards pragmatic NTD action.
In a subsequent policy document, ‘Accelerating Work to Overcome the Global Impact
of Neglected Tropical Diseases: A Roadmap for Implementation’ (WHO 2012), WHO
listed fourteen ‘major donations of medicines for controlling neglected tropical diseases
by the pharmaceutical industry’. Assessing the Roadmap, it is arguable that beyond
charitable donations, the global politics and governance of NTDs should focus on align-
ing the strategies, skills, and strengths of the diverse and multiple actors for effective
partnerships that address private sector interests, including concerns over pharmaceut-
ical patents, without compromising the health needs of millions of poor people who live
with the burdens of NTDs. Partnerships often require a delicate balance between private
sector interests and public needs. Examples of innovative ideas include Medecins sans
Frontieres’ (MSF)/Doctors without Borders’ launch of the not-for-profit Drugs for
Neglected Diseases Initiative. According to Orbinski (2007, 35), this has created ‘new
affordable treatments for diseases that primarily affect poor people in the developing
world. The initiative began in 2003. . . . The goal is not to singularly assume the responsi-
bility for neglected disease R&D, but to demonstrate that alternatives to the current system
are possible, and to insist on political responsibility in achieving the needs-driven,
equity-oriented global R&D agenda as a public responsibility’. This initiative offered a
tactful policy pathway to navigate through the intellectual property (patent) highway.
As ‘t Hoen (2009) observed, the patent policy of the Drugs for Neglected Diseases
Initiative (DNDI) regards ‘drug research as a public good that should primarily lead to
the advancement of health’. In addition to the proposals from civil society organisations
 Global Politics of Neglected Tropical Diseases   573

such as MSF, in 2009 Novartis, a leading pharmaceutical corporate actor, proposed

The Fund for Research in Neglected Tropical Diseases (FRiND) (Herrling 2008).
FRiND was originally envisaged to become a dominant funder of neglected diseases
research. Albeit ambitious in its original scope and coverage, this was subsequently
scaled down because of donor fatigue from most stakeholders.
Should WHO, as the intergovernmental institution with a mandate to coordinate
international health work, take the lead in midwifing these types of innovative partner-
ships for each of the seventeen NTDs (see Table 29.1)? Is there any coherent synthesis
between the ‘health as a public good’ argument and the postulation that intellectual
property (patent) serves as an incentive for innovative private-sector-led ‘production’ of
goods? An assessment of health as a ‘global public good’, however, is a complex intellec-
tual endeavour (Smith et al. 2003; Kaul et al. 1999, 2003). In principle, public goods are
characterised by two essential features: non-excludability (the benefits are unrestricted,
and available to all), and non-rivalry in consumption (the consumption by one person
does not limit consumption of the same good by others). Because most goods are private
in nature, or at least in the case of medicines produced largely in the private domain by
pharmaceutical companies, striking a balance between intellectual property and health
as a public good is a daunting task. In 2001 the WHO Commission on Macroeconomics
and Health tackled these tensions head on by recognising that the ‘production of new
knowledge, especially through investments in research and development (R&D)’ is an
important kind of public good (WHO 2001b, 77). Proposing a pragmatic approach, the
commission (WHO 2001b, 77) persuasively argued:

Since knowledge is ‘non-rival,’ meaning that the use of knowledge by one person
does not diminish its availability for others, it makes sense for society to ensure that
new knowledge is widely available and actually used. Yet if the fruits of R&D are
freely available, profit-maximising firms will lack the incentive to invest in R&D in
the first place. The pragmatic approach in balancing the need for availability of
knowledge with the need for private incentives to invest in R&D is to combine two
policy instruments: public financing of R&D in combination with patent protection
for private investors in R&D.

Turning to R&D directed at diseases endemic in poor countries, the commission rightly
observed that the ‘incentive mechanisms fail at both ends,’ for two reasons. First, the
governments of poor countries would lack the funds to subsidise R&D. Second, patent
protection carries little value when there is no significant market at the end of the R&D
process. Because poor countries benefit from R&D when the rich also suffer from the
same diseases, the commission distinguished amongst three types of diseases. Type I dis-
eases are prevalent in both rich and poor countries, with large numbers of vulnerable
populations in each. Type II diseases are incident in both rich and poor countries, but with
a substantial proportion of the cases being in the poor countries. Type III diseases are those
that are overwhelmingly or exclusively incident in the developing countries, such as
African sleeping sickness (trypanosomiasis) and African river blindness (onchocerciasis)
Table 29.1 Neglected Tropical Diseases—Summary
Disease Description Control & Treatment Global Morbidity & Mortality

Dengue1 A mosquito-borne infection causing Control of mosquito vector to stop Estimated 390 million infections annually,
flu-like illness that may develop dengue spread is prioritised. Only with 3.9 billion at risk.
into severe dengue and cause lethal symp­to­matic treatment available.
complications. Global incidence has Prophylactic vaccine carries a risk of Around 500,000 hospitalised each year
grown due to urbanisation; half of severe dengue with repeated infection due to severe dengue, with estimated
the global population is at risk. and has yet to be implemented as a 2.5% case fatality.
preventative measure.
Rabies2 A preventable viral disease transmitted to Post-exposure prophylactic (PEP) vaccine > 15 million receive PEP worldwide annually.
humans through the bites of infected and immunoglobulin exist but are not Predominantly affects the poor who live in
animals that is invariably fatal once widely available or accessible. Average remote rural areas.
symptoms develop. cost of rabies PEP is USD 40 in Africa Estimated 59,000 deaths annually, 95% of
and USD 49 in Asia. Mass dog vaccination which are in Asia and Africa.
(> 70% canine population) is also
employed as a preventative measure.
Trachoma3 A chlamydial infection transmitted Control of the disease is by elimination Estimated 2.2 million are visually impaired
through direct contact with infectious eye of the infectious agent through good due to trachoma in Africa, Asia, Central and
or nasal discharge or through indirect sanitation and hygiene and access to South America, and Australia; of which 1.2
contact with unsafe living conditions and clean water. million are blind. Women are at greater risk
hygiene practises, which left untreated Trachoma is treatable with antibiotic and for blindness due to exposure as caregivers
causes irreversible corneal opacities and corrective surgery (average cost USD 40). to adults and children infected with
blindness. No vaccines available. trachoma.
Buruli ulcer4 A debilitating mycobacterial skin infection Early detection and treatment with In 2015, 2,037 new cases were reported
causing severe destruction of the skin, antibiotics are vital to prevent permanent from 13 countries; most patients are
bone, and soft tissue. loss of functionality. No vaccines children under 15 years of age.
available.
Yaws5 A chronic bacterial infection affecting No specific preventions besides promot- As of 2015, > 46,000 cases reported
mainly the skin and bone that can lead to ing personal hygiene and health worldwide.
disfigurement and disability. education. Early infection is treatable with
antibiotics. No vaccines available.
Leprosy6 A complex disease caused by infection Exact mechanism of transmission is not Global registered prevalence in 2015 was
mainly of the skin, peripheral nerves, known; no specific preventative measures 176,176 cases.
mucosa of the upper respiratory tract, or vaccine available. Leprosy is treated
and eyes. using multi-drug antibiotic therapy
similar to that for tuberculosis.
Chagas disease7 A life-threatening illness transmitted to Vector control and screening of blood Estimated that 10,000 people die from
humans through contact with vector product in endemic areas are crucial. Chagas disease annually; 25 million remain
insects (triatomine bugs), ingestion of Infection is treated with nifurtimox and at risk.
contaminated food, infected blood benznidazole.
transfusions, congenital transmission,
organ transplantation, or laboratory
accidents.
Human African A parasitic infection spread by the bites Vector control and early treatment has Estimated number of cases since
trypanosomiasis8 of tsetse flies that is almost 100% fatal been credited for the lower number of 2015 is < 20,000; estimated population
(sleeping sickness) without prompt diagnosis and treatment cases since the 2000s. WHO public- at risk stands at 65 million people.
to prevent the parasites invading the private partnership with Sanofi and Bayer
central nervous system. was pivotal to this reduction.
Leishmaniasis9 Disease transmitted through the bites of Vector control to prevent leishmaniasis is Estimated 700,000–1 million new cases
infected female sandflies that in its most difficult because sandfly control requires annually, of which 50,000–90,000 are
severe (visceral) form attacks the internal complex environmental management and visceral leishmaniasis, with > 95% fatality
organs and in its most prevalent domestic sanitation. Leishmaniasis is rate if untreated.
(cutaneous) form causes face ulcers, treatable but often affects populations in
disfiguring scars, and disability. remote areas with little to no healthcare
access.
Dracunculiasis10 A nematode infection transmitted Vector (water fleas) control has been 21 cases reported in 2018.
(guinea-worm disease) exclusively by drinking-water contamin- effective in lowering the transmission of
ated with parasite-infected water fleas. guinea worm.

(continued)
Table 29.1 Continued
Disease Description Control & Treatment Global Morbidity & Mortality

Echinococcosis11 Infection caused by the larval stages of Deworming of sheep, canine, and other >1 million are affected by tapeworms at any
tapeworms forming pathogenic cysts in hosts is the most important method to given time, causing an estimated 19,700
humans and transmitted when ingesting lower transmission of Echinococcus deaths and 871,000 disability cases annually.
eggs, most commonly shed in faeces of tapeworm. Treatment is expensive and
dogs and wild animals. difficult; patients often suffer reduced
quality of life even with treatment.
Foodborne Infection acquired by consuming fish, Improving sanitation and clean Estimated 2 million deaths and disabilities
trematodiases12 vegetables, and crustaceans contaminated water access is necessary to interrupt annually.
with larval parasites; clonorchiasis, the infection cycle. Preventative
opisthorchiasis, and fascioliasis are the chemotherapy is available.
main diseases. Flat worms affect organs
such as liver, bile duct, and brain.
Lymphatic filariasis13 Infection transmitted by mosquitoes Control of mosquito vector is the primary Estimated 36 million people live with the
causing abnormal enlargement of limbs preventative measure. Chemotherapy is chronic manifestation of the infection.
and genitals, from adult worms inhabiting available to eliminate microfilaria.
and reproducing in the lymphatic system. Chronic manifestation often leads to
disability and poor quality of life.
Onchocerciasis14 Infection transmitted by the bite of Control of blackfly vector is Estimated 20.9 million are infected; of
(river blindness) infected blackflies, causing severe itching ­recommended to interrupt transmission. which 14.6 million have skin disease and
and eye lesions as the adult worm Chemotherapy is available. 1.15 million suffer vision loss.
produces larvae and leading to visual
impairment and permanent blindness.
Schistosomiasis15 Trematode infections transmitted when Control through improving access to Estimated deaths range from 24,000 to
larval forms released by freshwater snails clean water, safe sanitation, hygiene 200,000 per year.
penetrate human skin during contact education, and vector control.
with infested water. Chronic infection in Chemotherapy is available.
children causes anaemia, stunts growth,
and affects learning ability.
Soil-transmitted16 Nematode infections transmitted through Periodical deworming treatment, Approximately 1.5 billion infected at any
helminthiases soil contaminated by human faeces, improved sanitation and clean water given time.
causing anaemia, vitamin A deficiency, access, and hygiene education are needed
stunted growth, malnutrition, intestinal to control the infestation. Chemotherapy
obstruction, and impaired development. is available.
Mycetoma17 Mycetoma is a chronic, progressively Treatment is often expensive and Global health burden is unknown; endemic
destructive inflammatory skin disease unsatisfactory, has many side effects, and in Asia, Latin America, Africa, and Europe.
that usually affects the lower limbs. may require surgery. Footwear can protect
Infection is thought to be caused by the against puncture wounds that lead to
inoculation, through a thorn prick or skin mycetoma, but may not be affordable for
damage, of fungi or bacteria into the the poor in endemic regions.
subcutaneous tissue.

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

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

NTDs, SDGs, and ‘Leaving

No One Behind’

In September 2015 world leaders adopted an ambitious set of seventeen sustainable

development goals (SDGs) and 169 targets and indicators after a long and tortuous con-
sultative process led by the United Nations. The SDGs, which succeeded the Millennium
Development Goals, would guide the global development agenda until 2030. Influenced
by the Report of the High-Level Panel established by the UN Secretary-General, the
SDGs are driven by five large transformative concepts: leave no one behind; put sustain-
able development at the core; transform economies for jobs and inclusive growth; build
peace and effective, open, and accountable institutions for all; and forge a new global
partnership. Health is primarily anchored in SDG 3: ‘Ensure healthy lives and promote
 Global Politics of Neglected Tropical Diseases   579

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

Enlightened self-interest compels both industrialised country governments and

private corporations to do what it takes to drastically reduce the current burden of
disease in the developing world. To do so will be good for economic growth, be
good for health and be good for the environment. Not only for the three billion
people who have yet to benefit from the technological and economic revolution of
the past fifty years—but for us all.

In addition to self-help and enlightened self-interest, tackling the burdens of NTDs in

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

Conclusion

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

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

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 chapter 30

The Politics of
Gl oba l Vacci nation
Policies

Stuart Blume

In attempting to control, prevent, or eradicate infectious diseases, global health policy

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

A New Tool for Public Health

In the mid-nineteenth century, as public health was becoming a field of state action,
vaccines were of minor importance. Depending upon what were thought to be the
causes and modes of disease transmission, as well as political and administrative tradi-
tions, practises emphasised either sanitary measures or quarantine. Insofar as infectious
disease was thought to be the result of contagion, restrictions on the cross-border move-
ment of travellers, as well as goods that might harbour an infectious agent (e.g., bales of
cotton or wool), made sense. Such measures, however, led to tensions with the business
community, which perceived them as restrictions on the flow of trade, as well as with
foreign governments, which suspected deliberate attempts to hinder their commercial
interests (Baldwin 2005; Harrison 2012). One early benefit of microbiology, emerging as
a new discipline at the time, was that it permitted late nineteenth-century scientists to
establish whether a given individual, or a given bale of merchandise, was infected. This
alleviated the need to use blanket quarantines. Soon afterwards, the same basic science
was used to create what were to become some of public health’s most effective tools,
including vaccines.
The principle of vaccination was not new. In the late eighteenth century, Jenner had
already established that infection with a mild pathogen (cowpox) offered protection
against a related, but far more serious, one (smallpox). Thereafter, many countries began
to vaccinate their populations against smallpox, and in many places smallpox vaccination
was made compulsory. In England, for example, smallpox vaccination was made com-
pulsory in 1853 and administered by the Boards of Guardians, responsible for adminis-
tering the Poor Laws in local parishes. Here, as in many other countries, the element of
compulsion backed by penalties led to controversy and protest.
From a scientific perspective, for many years it was taken for granted that the use of a
mild infection to protect against a more serious one was only feasible when two closely
related conditions were involved. When Pasteur demonstrated that this was not neces-
sary and that weakened (or ‘attenuated’) pathogens could work just as well, he pointed
the way to key advances in health technologies. First, however, the bacterium respon-
sible for each individual disease would need to be identified and cultured in the labora-
tory. Scientists turned their attention to the major diseases of the period: tuberculosis,
diphtheria, cholera, and typhoid. By the time a diphtheria ‘antitoxin’ was developed, at
the end of the nineteenth century, systems for administering and delivering smallpox
vaccination were in place in many countries. Whilst these systems might have been
deployed to administer the new diphtheria serum, they were not. This was not only
because of the unpopularity of state-mandated vaccination. Despite the fact that diph-
theria was a dangerous childhood disease, no one considered large-scale prophylactic
vaccination against it. Instead, the serum was used in hospitals to treat young patients.
It was not until after World War I, during which preventive vaccination of soldiers
against typhoid (caused by Salmonella typhi) proved so successful, that prophylactic
 Politics of Global Vaccination Policies   585

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

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

Mass Vaccination after

World War II

The role of wartime conditions in facilitating the spread of infectious diseases and adding
urgency to the search for effective public health interventions applied equally during
World War II. Hostilities officially ended in 1945, but the health emergency created by
the conflict continued long after. Central and Eastern Europe were devastated by bomb-
ing and foreign occupation, and large swathes of the surviving population were left
displaced, homeless, and half-starved. Infectious disease control in the rest of the world,
viewed by the League of Nations Health Organization during the 1920s as a problem for
colonial powers, had received little attention during the war years (Worboys 2000).
After 1945, with talk of decolonisation in the air, this attitude began to change (Worboys
and Condrau 2010).
It is in this context that practises concerning vaccination also began to change. At the
1949 Commonwealth and Empire Tuberculosis Conference, a number of delegates
spoke in support of TB vaccination in the British colonies, where facilities were inad-
equate for large-scale treatment (Altink 2014). In Britain, too, there was a willingness to
rethink BCG vaccination, even though a number of leading medical specialists were
unconvinced of its value. Ultimately, administrative considerations, not scientific ones,
were to prove decisive. Recruitment to the nursing profession was suffering from the
widespread view that contact with TB patients was risky. Vaccination had the potential to
provide reassurance to potential recruits and avert the threatened shortage. Objections
regarding efficacy were also becoming muted. In 1949 BCG vaccination began to be
offered to nurses. By 1956 positive results were emerging from a Medical Research
Council (MRC) trial amongst fifty-six thousand schoolchildren. However, mass vaccin-
ation of children was already under way. Greater commitment to vaccination as a
component of preventative healthcare fit well with the British government’s plans for its
new National Health Service (NHS).
Matters were far more urgent in countries that had suffered under German occupa-
tion. Travelling around Poland in 1946, a Danish relief mission found TB to be rampant
and local facilities to deal with the disease wholly inadequate. Neither mass radiography
nor the recently developed antibiotic streptomycin was available on the scale needed.
The BCG vaccine seemed the only feasible approach, and in early 1947 a Danish Red
Cross team began vaccinating Polish children. In the first six months of the campaign,
forty-six thousand children were vaccinated.
Support for extending vaccination further soon came from the United Nations
Children’s Emergency Fund (UNICEF), created in 1946 to provide food, clothing, and
 Politics of Global Vaccination Policies   587

healthcare to children in a number of devastated European countries (Brimnes 2008;

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

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

Vaccine Cooperation Amid

Cold War Rivalries

Following the end of World War II, as the industrialised world became increasingly
polarised, Eastern and Western bloc countries had different visions of how public health
systems should be established and organised, both domestically and in parts of the
developing world where they competed for influence. Notably, political leaders on both
sides of the ideological divide felt that noteworthy success in controlling the spread of
infectious diseases would reflect well on their respective political systems. Vaccine
researchers had little difficulty in cooperating across the ideological divide to develop
new vaccines against diseases such as poliomyelitis. In contrast, as vaccines were turned
into symbols of ideological rivalry, their application became loaded with political sig-
nificance (Litsios 2002; Vargha 2014).
In divided post-war Germany, this Cold War rivalry played out particularly visibly.
The Federal Republic of Germany (FRG), and specifically the western-controlled section
of Berlin (which had special administrative status), developed vaccine policies with one
eye on what the East Germans were doing (Lindner and Blume 2006). In April 1960 the
German Democratic Republic (GDR) began vaccination using Albert Sabin’s oral polio
vaccine (OPV). Within a year almost the entire population had been vaccinated. The
FRG, where responsibility was vested in the individual Länder, had started using Jonas
Salk’s rival inactivated polio vaccine (IPV), but only succeeded in vaccinating a small
proportion of its population. These successes and failures were portrayed as a reflection
on the different political systems within which they were undertaken. The FRG’s failure
concerned far more than disease prevention. Ideological competition between the two
German states proved a key factor that eventually goaded West German authorities into
action. Another was international pressure. At international polio conferences, the
FRG’s poor record soon became a matter of growing political embarrassment. Having
started IPV vaccination with little enthusiasm, just a few years later West German
Länder jostled amongst themselves to be the fastest, and the most efficient, in introducing
free OPV vaccination. The programme was an immediate success, with twenty-three
million people vaccinated in 1962.
 Politics of Global Vaccination Policies   589

The High Politics of Malaria

and Smallpox Eradication

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

to neighbouring India. Regionalism, heightened nationalist sentiments, and ethnic and

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

The Expanded Programme on

Immunisation: Discursive Compromise
and National Autonomy

As the campaign for smallpox eradication progressed triumphantly, experts in inter-

national health began to wonder if it could provide a model for other vaccination pro-
grammes. Infectious diseases were by far the most important public health problem in
tropical countries, and it was thought that if children were mass vaccinated, the accrued
health gains would be substantial (Bulatao 1993). Of the eighty million children born
annually in the African, Latin American, and Southeast Asian regions, only around four
million were being effectively immunised during the 1970s. Furthermore, experience in
the Northern Hemisphere showed that smallpox, diphtheria, pertussis, tetanus, polio-
myelitis, and measles, and to some extent tuberculosis and typhoid fever, could be
brought under control through vaccines. Thus, in late 1973 WHO set up an internal
working group that fleshed out the idea of an expanded programme.
In May 1974, as the smallpox campaign was entering its final stages, the WHA adopted
Resolution 27.57, establishing what became known as the Expanded Programme on
Immunisation (EPI). The resolution recommended that WHO member states “develop
 Politics of Global Vaccination Policies   591

or maintain immunisation and surveillance programmes against some or all of the

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

approach (prioritising primary healthcare rather than disease-specific interventions),

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

Economic Globalisation and

Disease Eradication

During the 1980s, in the early years of EPI, support for local vaccine production and the
establishment of local and regional vaccine markets were accepted as important policy
objectives. A decade or so later, in a very different ideological climate, discourse had shifted,
and these objectives were quietly abandoned. The new neo-liberal climate emphasised
privatisation, the freer play of market forces, a reduced role for the state, and additional
 Politics of Global Vaccination Policies   593

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

of new and more effective vaccines, ultimately leading to a universal vaccine containing
all the antigens children require. Over the following ten years, unbridgeable disagree-
ments emerged between the CVI’s European and American donors. The Europeans felt
that the organisation was overly committed to technological solutions to address public
health problems. Despite shifting its focus from development of new vaccines to sup-
porting vaccine introduction, the CVI was closed down in 1999. Out of its ashes emerged,
phoenix-like, a new institution with far greater resources (Muraskin 2005). The Global
Alliance for Vaccines and Immunisation (GAVI), now known as the GAVI Alliance, was
announced at the World Economic Forum in 2000. Amongst its principal sponsors, in
addition to donor governments, were a number of nonstate actors, including the Bill
and Melinda Gates Foundation and the International Federation of Pharmaceutical
Manufacturers Associations (IFPMA). With a twenty-eight-member governing board
that includes representatives of low- and middle-income as well as donor countries,
industry, and civil society, the GAVI Alliance assumed a key role in articulating and
implementing global vaccine policy. Its policy emphasises accelerated introduction of
new vaccines, and the organisation subsidises their introduction in low-income countries
(defined according to World Bank criteria).
Alongside the shift towards economic considerations as an increasingly important
determinant of vaccination policies was a return to the view that campaigns should aim
not merely at controlling diseases, but at eradicating them. Though the roots supporting
eradication are deeper, justification was clearly drawn from the officially announced
successful global eradication of smallpox. At the time, WHO director general Mahler
warned the world that “important lessons can be learned from smallpox eradication—
but the idea that we should single out other diseases for worldwide eradication is not
amongst them. That idea is tempting but illusory” (Birn 2011). His concern was that tar-
geting eradication would further divert attention and resources from the structural and
economic roots of ill-health and from the commitment to strengthening primary
healthcare, which he saw as fundamental.
Despite Mahler’s cautionary words, within a few months of smallpox eradication,
moves to establish a follow-up eradication programme were under way (Muraskin 2012).
A meeting was organised at the US National Institutes of Health (NIH). Though two of
the principal architects of smallpox eradication, Frank Fenner and D. A. Henderson,
argued that there were no feasible eradication targets, the organisers of the meeting were
undeterred. The smallpox campaign had to be followed up, in their view; it mattered less
what the target of a subsequent campaign would be. Measles and polio were put forward
as the most likely candidates. There was a growing feeling in the CDC that measles
eradication was feasible now that a more heat-stable vaccine had been developed and
also desirable given that measles caused 900,000 deaths annually. Others, including
Fenner and Henderson, questioned whether eradication, rather than disease control,
should be a goal of global policy. Meanwhile the preference of the CDC eradicationists
was swinging towards polio rather than measles. At a symposium on polio control held
in Washington, DC, in 1983, almost no participants spoke in favour of a polio eradication
campaign. Polio was not a major public health concern in the developing world, and
control was deemed a more appropriate goal.
 Politics of Global Vaccination Policies   595

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

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

The Dynamics of Vaccination

Policies Today

A decade ago political economist Alice Amsden examined the impact of US policy on
development and on institutions such as the World Bank that support it (Amsden 2007).
She argued that the United States had forced a transformation in the policies and practises
 Politics of Global Vaccination Policies   597

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

However, vaccination schedules are a national responsibility, and differences remain,

even amongst European countries. For example, about half of these have no compulsory
vaccinations, whilst the others have one or more, most commonly polio. Both France
and Italy extended mandatory vaccination at the beginning of 2018. In Italy the ruling
was reversed six months later by the new populist coalition government. Irrespective of
whether vaccination is mandatory or voluntary, vaccination rates in Western European
countries are generally high. At the same time, the number of vaccines routinely offered
to babies and infants is rising. A baby born today is likely to receive twice as many vaccines
as its grandparents. How does this come about? On what basis do governments decide
to introduce a new vaccine? In many countries a standing expert committee provides
ministers of health with precisely this kind of advice. In the United States it is the
Advisory Committee on Immunization Practices (ACIP), and in Britain it is the Joint
Committee on Vaccination and Immunisation (JCVI). When a recommendation relat-
ing to a new vaccine is required, mortality and morbidity data relating to the disease
in question are reviewed, and the cost-effectiveness of the new vaccine is estimated.
In Britain a vaccine will be recommended only if its cost will be less than £3,000 per
quality-adjusted life year (QALY) gained.
Whilst policy decisions, including vaccine policies, are supposedly evidence based,
this rationalisation of the policymaking process assumes that all necessary data are
available, and that decisions are not influenced by lobbying by vested interests. However,
studies of actual decision-making suggest that these assumptions are not always justified
(Sandberg and Justice 2013). In many cases, national data are lacking, and practises else-
where are followed instead, even though the epidemiology of a disease may well differ
from one region or climate to another. For example, the measles vaccine is known to be
safe and effective but only 80 percent protective after a single dose. The vaccine should
be given when an infant’s maternal antibody levels are neither too high to interfere with
the effects of the vaccine nor too low to offer protection. In low-income countries in
tropical climates, the intensity of exposure to measles virus is higher. Maternal antibodies
also decline more rapidly than in temperate countries, so that infants are at risk of
acquiring measles at a younger age. There are thus good epidemiological reasons for
following a measles vaccination schedule different from that employed in Northern
Hemisphere countries. However, since the studies needed to establish the optimum
schedule for immunisation are costly and time-consuming, many low-income countries
are obliged to use evidence from elsewhere (Behague et al. 2009). In India, public health
activists have criticised the evidence base for domestic vaccine decision-making
(Madhavi et al. 2010). They argue that when replacement of a four-component by a five-
component vaccine was being considered, the government’s technical advisory body
ignored evidence suggesting that this would yield little or no extra health benefit in
India. A similar critique regarding the introduction of hepatitis B vaccine had been
made previously (Madhavi 2003). In the latter case, the decision to introduce the vaccine
was reportedly based on pressure from international organisations and the country’s
thriving biotech industry, rather than on epidemiological evidence from India itself,
which did not exist at the time.
 Politics of Global Vaccination Policies   599

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

Conclusion

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

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

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 chapter 31

The Gl oba l Politics

of Acce ss to
M edici n es
From 1.0 to 2.0

Suerie Moon and Ellen ‘t Hoen

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

Background

Access to medicines has been one of the most politically polarised issues in global
health. In 2010 Dr Margaret Chan, then director-general of the World Health
Organization, remarked at an annual meeting of WHO, the World Trade Organization
(WTO), and the World Intellectual Property Organization (WIPO): ‘Of all the issues
discussed at WHO governing bodies, access to medicines consistently sparks the most
heated, sometimes divisive, and potentially explosive debates’ (Chan 2010). It has given
rise to street protests; been the subject of intense lobbying by corporations, governments,
and non-governmental organisations (NGOs); and frequently pitted governments of
the global North against the global South in intergovernmental arenas.
606   Suerie Moon and Ellen ‘t Hoen

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

Why Does Access to Medicines

Matter to People and
Health Systems?

Medicines are a necessary component of fulfilling the right to health. They can alleviate
suffering. They can prevent, diagnose, and treat disease, thereby saving lives. They can
control and stop outbreaks of infectious disease. They can provide security to a popula-
tion and reduce panic, stigma, and fear related to disease. They are a necessary input for
any health system to function and on average comprise 20–30 percent of a society’s
total health expenditure. In general, the poorer the country, the larger the share of total
health spending dedicated to medicines; in some of the poorest countries, medicines
account for 30–60 percent of health spending. Therefore, medicine prices are of par-
ticular concern to developing countries, where on average higher disease burden, com-
bined with lower capacity to pay and higher reliance on medicines, make the cost a
critical social issue. Furthermore, unlike other health services that are often covered by
public or private insurance, medicines are frequently financed by out-of-pocket spend-
ing, making prices a particularly regressive financial burden on individuals and house-
holds (Lu et al. 2011).
Medicine use has been steadily increasing over the past decade and is projected to
continue doing so. Economic growth in middle-income countries (MICs), ageing popu-
lations worldwide, and the growing burden of chronic diseases that often require long-
term medicine use all suggest that access to medicines will continue to be a major
societal challenge and pressing political issue in the decades to come.
 Global Politics of Access to Medicines   607

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

How Have Concerns about Access to

Medicines Shaped Global Health?

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

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

History

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

History of Concerns Regarding Medicine Access

Medicine policy debates began to ‘globalise’ in the 1970s when WHO began working on
its first ‘Essential Drugs List’, published in 1977 and containing 207 items ‘that satisfy the
priority health care needs of the population’ (Wirtz et al. 2017). At the time, policy
debates and objectives did not focus centrally on ‘access,’ as they later would; rather, a
range of concerns relating to pharmaceutical policy in developing countries was on the
agenda, from marketing of dangerous medicines to appropriate use, and from quality
of production to affordable prices. The essential drugs concept was pioneered as part of
the drive for primary healthcare. In 1978 the Alma Ata Conference outlined an agenda
to achieve ‘health for all by the year 2000’ in which the selection and supply of essential
medicines was identified as a core function of the government (‘Declaration of Alma-
Ata’ 1978). Dr Halfdan T. Mahler was the visionary director-general of WHO at that time
and a driving force behind the concepts of primary healthcare and essential drugs.
In 1982 he established a dedicated WHO programme to encourage the availability and
correct use of essential medicines called the WHO Action Programme on Essential
Drugs, which became known as the Drug Action Programme.
One of the earliest NGOs to work on pharmaceutical policy issues at the international
level was Health Action International (HAI), founded in 1981 in response to the rallying
 Global Politics of Access to Medicines   609

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

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

History of Concerns Regarding Innovation in Medicines

In parallel to concerns about access to medicines, concerns about the ways in which new
medicines were developed were also emerging—in particular, whose health conditions
were (or were not) met, how well-adapted medicines were (or were not) for different
parts of the world, and who could (or could not) ultimately benefit from advances in sci-
ence and technology. The period from the 1970s to 2000 witnessed a significant shift in the
global R&D system and norms regarding whom it should serve. Whereas modern pharma-
ceutical development was focused in a handful of industrialised countries after World
War II, by the turn of the millennium a global innovation system had emerged populated
 Global Politics of Access to Medicines   611

by global networks of scientific researchers and labs, multinational pharmaceutical

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

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

Access to Medicines Politics 1.0

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

HIV and Patents

At the turn of the millennium the global HIV/AIDS pandemic had reached an alarming
scale and was increasingly recognised as a health, development, human rights, and
 Global Politics of Access to Medicines   613

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

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

the TRIPS Agreement does not and should not prevent members from taking meas-
ures to protect public health. Accordingly, whilst reiterating our commitment to the
TRIPS Agreement, we affirm that the Agreement can and should be interpreted and
implemented in a manner supportive of WTO members’ right to protect public
health and, in particular, to promote access to medicines for all. (WTO 2001)

The Doha Declaration strengthened and expanded the policy space available to govern-
ments to protect public health in the global IP regime. Other key provisions of the Doha
Declaration included explicit assurance permitting parallel importation (trade in
patented products when available at different prices in different countries), clarification
 Global Politics of Access to Medicines   615

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

Discussion
The political conflict over access to HIV medicines and IP rules can be seen as a first
phase of global access to medicines politics—what we label ‘1.0’. Some observations
regarding the politics of 1.0 are merited. First, access issues involved many different
actors: governments in the global North and South, multilateral organisations (pri­ma­rily
616   Suerie Moon and Ellen ‘t Hoen

the WTO and WHO, but also WIPO, UNDP, the UN Human Rights Commission/
Council, and UNCTAD), local and international NGOs, the pharmaceutical industry,
academic experts, moral leaders, and foundations. At the turn of the millennium, the
political alignments were relatively clear and strongly polarised: northern governments
and the patent-holding originator pharmaceutical industry advocated for strict IP rules
on one side; southern governments, generic pharmaceuticals, and NGOs pushed for
flexible IP rules on the other; and multilaterals caught in the crossfire and various other
non-state actors chose sides. Each of these actors brought different power resources to
the political conflict. The North and industry had economic power, diplomatic muscle, a
range of preferred experts, and influence over multilateral organisations by virtue of their
major role as funders. The South and NGOs had the weight of global public opinion on
their side, diplomatic strategies, a range of their own preferred experts, moral leaders,
and strength in numbers in multilateral arenas. The Doha Declaration was the result of a
combination of the uniquely alarming proportions of the HIV/AIDS crisis, the diplo-
matic manoeuvrings of southern governments, the political savvy of activists, and the
coincidence of the post-9/11 anthrax crisis in the United States (Hein and Moon 2013).
After Doha, as donor money began to flow towards expanding access to HIV treat-
ment in developing countries, a shift in this political alignment became discernible.
Both the Global Fund and PEPFAR, funded mainly by northern governments, purchased
primarily generic medicines. Pharmaceutical companies were increasingly expected to
make their medicines available and affordable in developing countries, at least for the
few issues that had become global priorities: HIV, malaria, tuberculosis, and childhood
vaccines. In low-income countries where no markets were at stake, the industry largely
dropped its opposition to more flexible approaches to IP protection, particularly for
HIV. For example the IFPMA did not oppose the request by LDCs at the WTO for
extension of exemptions to the implementation of the TRIPS Agreement from 2006 to
2016, then later to 2033 (IFPMA 2015). The road was not always smooth; a number of
legal disputes broke out in sub-Saharan Africa, Thailand, and Brazil relating to patents
on medicines in the post-Doha years. But over the course of the ensuing decade what
gradually solidified was what Hein and Moon (2013) have called an ‘access norm’—that
is, widespread acceptance of the idea that medicines should be affordable to those who
need them. After UNITAID decided to create the Medicines Patent Pool (MPP) in 2009
to negotiate voluntary licences with pharmaceutical companies to authorise generics
in developing countries, the companies one-by-one came on board. Whilst civil society
and UN pressure initially played a role in convincing them to do so, it is a remarkable
shift that companies that were vehemently opposed to making their medicines widely
affordable in the global South in 2001 voluntarily agreed to do so in over one hundred
countries a decade later. As of 2016, all WHO-recommended ARVs were licenced to
the MPP, and MPP licences reached 87 to 93 percent of people living with HIV in low-
and middle-income countries (LMICs) (Juneja et al. 2017). In 2017 the MPP expanded
its scope to include two other diseases, hepatitis C and tuberculosis, and began working
to include all patented medicines on the WHO Essential Medicines List (Medicines
Patent Pool 2018).
 Global Politics of Access to Medicines   617

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

Deere 2008). The 2012 report of the WHO Consultative Expert Working Group on
Research & Development linked innovation and access issues inextricably together and
boosted the attention given to alternate financing models for R&D (Røttingen and
Chamas 2012). Such reports often reflected and solidified the evolution of political
debates and also created space for new ideas to be considered.
From 2000 until about 2015, the sum total of these developments was that an access
norm became relatively well-established, and significant experimentation and increasing
attention were devoted to medicine innovation. These developments laid the founda-
tion for a more nuanced and complex political dynamic to emerge, what we call ‘access
to medicines politics 2.0’.

Access to Medicines Politics 2.0

From its origins in the global movement for access to HIV treatment has grown a much
broader global political debate on medicines. The politics of access to medicines has
shifted in important ways, characterised by three major changes: an expansion from
focusing on HIV and neglected disease to all diseases; a reframing of the debate from
‘access’ to ‘innovation and access’ that inextricably links access challenges to the current
system of R&D; and a broadening of innovation and access concerns from developing
countries to all countries, even the wealthiest. We discuss each of these shifts in turn,
then consider their political implications.
First, attention has expanded beyond HIV medicines to a much broader set of dis-
eases for which new, highly priced medicines are being put on the market. Much of the
concern has focused on the high prices of hepatitis C and cancer medicines. Hepatitis C
medicines that could cure patients in twelve weeks were launched in the United States in
2013 at US$84,000 per treatment course, resulting in rationing amongst the sick and
record-level profits for the seller, Gilead (Canary, Klevens, and Holmberg 2015; Iyengar
et al. 2016). Cancer therapies, such as the Kymriah CAR-T treatment marketed by
Novartis and priced at US$475,000, threaten the sustainability of health systems in
high-income countries and are unimaginable for health systems in LMICs (Moon 2018).
These prices have made headlines in Western media, prompted criticism from the high-
est political levels, and launched a flurry of policy proposals to address them. It can be
expected that costly medicines for any disease offering significant therapeutic advance
are likely to generate the same type of political attention. From genomic or personalised
medicine to increasingly sophisticated reproductive technologies, advanced and costly
technologies that offer healthier, longer lives to those who can pay will continue to be
developed. Combined with the ageing of populations, this trend implies growing health
spending and struggles in all countries to handle the financial strain on health systems.
The second change is the shift in framing away from treating ‘innovation’ and ‘access’
as two separate issues to framing them as two sides of the same coin. As explained pre-
viously, debates on innovation—particularly that the R&D system failed to develop new
 Global Politics of Access to Medicines   619

medicines for the neglected diseases of the poor—historically evolved on a parallel track
with debates on access. One of the main responses to the problem of neglected diseases
was the launch of non-profit PDPs that sought to develop new products for use in devel-
oping countries, at affordable prices, based on a logic of collaboration amongst the PDP,
academia, governments, and industry. In some ways the PDPs were the polar opposite
of the dominant for-profit R&D model, which sought to develop new products for the
wealthiest countries, at the highest prices the market would bear, based on a logic of
competition amongst firms.
Non-profit R&D models with access as a core objective have matured as an alternate
organisational form in the fifteen to twenty years they have existed; several brought new
products to market and many had pipelines full of candidate products (Muñoz Tellez
de Kieffer 2015). There has also been increased recognition that the R&D system fails
to address not only the neglected diseases but also diseases that directly threaten all
countries—in particular, pathogens of pandemic potential (prompted by the 2014 Ebola
and 2016 Zika outbreaks) and antibiotics to combat the rise of antimicrobial resistance
(AMR). Increased scrutiny of current business models for R&D has produced new
thinking on how to change current practises to build access into the innovation process
from the start, and there appears to be renewed interest in alternate business models for
R&D that have affordability as a core objective. The concept of delinkage has become
increasingly prevalent in debates over how to reform the existing innovation system
(Love 2016). It is regularly adopted in UN and WHA resolutions, public debates, and
policy proposals for new incentives for R&D (‘t Hoen 2017).
The third major shift is an expansion of access challenges beyond developing coun-
tries, to affect all countries, even the wealthiest. In Switzerland, regularly amongst the five
wealthiest countries in the world if ranked by Gross National Income (GNI) per capita,
hepatitis C treatment was rationed for several years after the medicines were launched
due to budget constraints. In the United States health spending has long grown faster
than the overall economy (though it has stabilised in recent years),2 and spending on
medicines is growing even faster than health sector spending (Quintiles IMS 2017).
Medicine prices and the health benefit medicines deliver have become a political issue
of growing importance. In LMICs the challenges remain immense. The LMICs face
major financing gaps simply to provide a universal package of basic health services to
their populations; in sixty-seven LMICs achieving universal health coverage by 2030
will require an estimated additional investment of USD41–58 per person per year, which
will require major increases above current investment levels (Stenberg et al. 2017).
Expanding these budgets to pay for a growing arsenal of medicines and other health
technologies is a tall order. At the same time, development assistance for health has hit a
plateau after fifteen years of record growth (IHME 2016) and is likely to shift towards
low-income countries. Overall, donor funds to finance medicines will become more
scarce, especially in MICs. In many MICs, however, health spending is an increasing
proportion of the economy. For MICs shouldering the full burden of medicine financing,
there will be a strong incentive to push even harder for policy measures that give govern-
ments leverage to reduce drug prices. The right to health is included in the constitutions of
620   Suerie Moon and Ellen ‘t Hoen

a number of countries (Hogerzeil et al. 2006), such as South Africa and Brazil, which is
an important lever for ensuring access to medicines at the national level but also implies
growing future health expenditures.

Discussion
Taken together, these three shifts have important implications for the global politics of
access to medicines. First, there is likely to be a gradual erosion of the North-South
polarisation that has long dominated debates on access to medicines. In Europe, where
widespread publicly financed health insurance systems mean that rising medicine prices
directly impact government budgets, there has been high-level political criticism of the
traditional R&D system and resulting high prices. For example, the European Council
Conclusions of June 2016 expressed concern about the sustainability of medicine pricing
trends and set in motion a process of review and possible revision of EU pharmaceutical
incentive mechanisms (Council of the European Union 2016). This was a significant
shift away from what has long been a maximalist European Union position in inter-
national IP negotiations. More specifically, the Dutch trade and health ministers in 2016
called for increased transparency on R&D costs and drug pricing, new business models
for R&D, and no TRIPS-plus measures in new regional trade agreements (Ploumen and
Schippers 2016).
Instead of North-South politics, left-right divides that cut across all countries may
take prominence, with left-leaning actors arguing for a greater role for governments in
funding and regulating innovation and pricing, and right-leaning groups arguing for a
smaller one. If so, the politics will become more complicated, with political alliances
forming across groups of like-minded governments and non-state actors rather than the
simple two-camp positioning of the past. This also underscores the enduring import-
ance of domestic elections.
The shift from access to medicines being considered a developing country issue to
being a global issue may also open the door to more significant reform of the global
R&D system. Northern governments have far greater leverage to change the funding,
incentives, and regulations that govern innovation processes because they remain the
main source of public R&D investment and the largest medicine markets. More govern-
ments may demonstrate new political willingness to reform the R&D system as policy-
makers directly feel the budget implications of high drug prices.
In addition, the search for new R&D business models that can jointly deliver innov-
ation and access will challenge established political alignments. Measures to control
medicine prices, including but not limited to the use of IP flexibilities, have run directly
counter to the interests of patent-holding pharmaceutical companies. However, pro-
posals for R&D reform have tended to emphasise rewarding innovators (including but
not limited to corporations) for useful new inventions, albeit through means other than
market monopolies. Industry decision-makers willing to test new models of R&D may
find themselves aligned with NGOs, academics, and governments calling for the same.
 Global Politics of Access to Medicines   621

Furthermore, the gradual rise of MICs will also shape the politics of innovation and
access to medicines. Some MICs have increased their financial contributions to inter-
national R&D efforts. For example, the South African government has funded the
Global Antibiotics Research and Development Partnership (GARDP), a PDP launched
in 2017 to spur R&D for new medicines to combat antimicrobial resistance. Contributing
funding to R&D may shift the framing of access debates away from ‘charity’ or ‘develop-
ment aid’ towards a frame of ‘shared responsibility’ or ‘cooperation.’ MICs are also the
site of increasing domestic R&D activities. In 2017 China became the second largest
source of new international patent applications, surpassing Japan and trailing only the
United States (WIPO 2018). Domestic investment in R&D in China has grown rapidly,
more than doubling since 2000 to surpass 2 percent of GDP in 2016—matching the
average R&D investment ratio in Organisation for Economic Co-operation and
Development (OECD) countries, and approaching US R&D investment in absolute
terms.3 China and other MICs also face significant pressure to expand healthcare provi-
sion, including access to new medicines, as their economies grow. MICs’ governments
may face competing objectives: to promote their burgeoning domestic biopharmaceut-
ical industries and to ensure access to medicines for their domestic populations. Again,
the implication is a more complex political dynamic, with domestic political alignments
perhaps becoming more important than international North-South divides.
Finally, changes in the pharmaceutical industry itself are also likely to complicate glo-
bal medicine politics. Some in the industry have already signalled their willingness to
consider new R&D business models, most prominently in the area of antibiotics. In
addition, biotechnology firms have become an increasingly important source of innov-
ation, including many small and medium enterprises (SMEs) that spin off from aca-
demic laboratories. Testing new R&D business models may be more feasible with
SMEs, both because of the smaller scale of investment necessary and because many rely
on public grants (or venture capital investment) to keep their doors open. At the same
time, there has been significant consolidation in the industry, including the acquisition
of some major Indian generic firms by large multinationals (PriceWaterhouseCoopers
2018). Some generic firms may emphasise collaboration over competition with patent-
holders as a result. Market concentration of the largest firms may also further concen-
trate political power of the pharmaceutical industry and its ability to influence public
policies and debates. As with governments, on balance the politics appears set to
become more complex.

Conclusion

The question of how societies organise the research, development, pricing, and supply
of health technologies profoundly shapes who does and does not benefit from advances
in science and technology. These life or death questions have generated fierce political
conflict, which has in turn shaped the flows of billions of dollars in public and private
622   Suerie Moon and Ellen ‘t Hoen

resources. Innovation and access to medicines are likely to remain enduring issues for
both global and domestic politics in the decades to come. The rise of personalised medi-
cine, genomics, and other technological advances hold out the prospect of life-changing
inventions but also wrenching ethical debates about prices and access (amongst other
issues). The relevance of these debates will only increase with the ageing of populations,
growth of health spending in countries at all levels of development, and globalisation
of pharmaceutical research and production, particularly to MICs. The experience of the
past several decades suggests that a world in which medicines are increasingly sophisti-
cated, but available only to the lucky few, will not be politically sustainable. The politics
that shapes how national and global societies ultimately respond to these challenges is
likely to become increasingly complex in this ‘2.0’ era.

Acknowledgements
We are grateful to Danielle Mae Navarro for research assistance in preparing this manuscript.

Notes
1. Authors’ calculations of data from the World Bank, https://datacatalog.worldbank.org.
2. Data on health spending since 1960 from US Centers for Disease Control and Prevention,
http://www.cdc.gov/nchs/hus/healthexpenditures.htm#total.
3. Data on R&D investment in OECD countries from the OECD, https://data.oecd.org/rd
/gross-domestic-spending-on-r-d.htm.

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 chapter 32

Non- Com m u n ica bl e

Diseases a n d Gl oba l
Hea lth Politics

Roger Magnusson

Non-communicable diseases (NCDs) are responsible for nearly forty million deaths
each year (GBD 2015 Mortality and Causes of Death Collaborators 2016). Around
80 percent of these NCD deaths are caused by cardiovascular disease (CVD), cancer,
chronic respiratory diseases, and diabetes—diseases linked by a cluster of modifiable
behavioural and physiological risk factors, including tobacco use, harmful use of alcohol,
obesity, unhealthy diets, high blood pressure, and lack of physical activity (see table 32.1).
Since 1980, average life expectancy at birth has risen by ten years, and as a result NCDs
have become ‘the diseases of those with longer lives’ (Bollyky 2012).
Despite accounting for around 70 percent of global deaths each year, NCDs have been
spectacularly unsuccessful in attracting development funding for management and
prevention in low- and middle-income countries (Nugent 2016). For example, in 2015
development assistance for health (DAH) for NCDs represented only 1.3 percent of total
DAH. Whilst DAH for NCDs grew by more than 8 percent over the period 2000–2015, it
grew at a slower rate than other areas of health investment, and indeed fell by 3.4 percent
in 2015 (IHME 2015, 27, 65–67). Despite growing international diplomatic coordination
around NCDs, the reality is that the future of NCDs will depend substantially on coun-
tries’ capacity for self-help (Cassels 2015).
This chapter sets the scene by briefly describing how NCDs have emerged as a global
health challenge. Whilst NCDs affect individuals and are seen by some as the conse-
quence of personal failings and lifestyle choices, their global health impact is better
understood by focusing on the demographic, market, and political conditions that have
resulted in rising rates of behavioural and physiological risk factors across the population,
including in low- and middle-income countries. This chapter reviews the mixed success
of global efforts to create a future less burdened by NCDs. To do this, I present a simple
model for analysing the activities of global forums that have the capacity to drive
628   Roger Magnusson

Table 32.1 Mortality from NCDs in 2015

Selected Modifiable Behavioural and Selected Causes of Death
Physiological Risk Factors Contributing to Death

Metabolic risks: 16.9 million Non-communicable diseases:

39.8 million
High fasting plasma glucose: 5.2 million Cardiovascular disease: 17.9 million
High cholesterol: 4.3 million Cancers: 8.8 million
High blood pressure: 10.7 million Chronic respiratory diseases: 3.8 million
High body mass: 4 million Diabetes: 1.5 million
Dietary risks: 12.1 million Transport injuries: 1.5 million
Diet high in sodium: 4.1 million Cf. HIV/AIDS and tuberculosis:
2.3 million
Tobacco smoke: 7.2 million
Alcohol use: 2.3 million
Insufficient physical activity: 1.6 million
Cf. unsafe sex (all causes): 1.5 million

Source: GBD 2015 Risk Factor Collaborators (2016)

changes at the country level, including the World Health Organization (WHO) and
United Nations General Assembly (UNGA). Two important, overarching questions to
consider are: To what extent has the global political response to NCDs provided a cata-
lyst for the changes that will be necessary at the country level to wind back mortality and
morbidity? If prospects for future development assistance for addressing NCDs remain
grim, where are the opportunities for making progress?

Why Have NCDs Become

a Global Health Challenge?

Since 1960, life expectancy at birth has improved dramatically, rising thirteen,
twenty-three, and twenty-two years in high-, middle-, and low-income countries,
respectively, reaching eighty-one, seventy-one, and sixty-one years in 2014 (World Bank
2016). These improvements in life expectancy reflect the relative success of global efforts
to reduce child and maternal mortality and mortality from communicable diseases. The
result is more people ‘dying at lower rates and living to older ages’ (IHME 2016, 24).
However, running in parallel with this good news story is the global rise in
­lifestyle-related risk factors, including tobacco use, obesity, unhealthy diets, harmful use
of alcohol, drug use, lack of physical activity, high blood pressure, and high blood sugar
 Non-Communicable Diseases   629

levels. These risk factors—and the NCDs they cause—threaten healthy ageing and cause
premature mortality. At the global level, prevention and better treatment of NCDs have
progressively reduced the age-standardised rate of disability adjusted life years (DALYs)
from NCDs. On the other hand, the overall rate of increase of the adult population in
countries that have undergone the demographic transition—and now have more adults
living to older ages—means that the absolute burden of NCDs is rising and will continue
to do so (GBD 2015 Mortality and Causes of Death Collaborators 2016; IHME 2016, 35).
Two points about the global rise in NCDs deserve emphasis. First, NCD risk factors
are driven by markets: for tobacco, alcohol, highly processed foods, and sugary bever-
ages (Moodie et al. 2013; Stuckler et al. 2012; Monteiro et al. 2013). These markets have
expanded rapidly in developing countries as a result of trade and investment liberalisa-
tion policies that lead to increased levels of direct foreign investment, imports, and
advertising (Baker, Kay, and Walls 2014; Labonté, Mohindra, and Lencucha 2011; Friel et
al. 2013; Hawkes, Chopra, and Friel 2009). For example, Lopez and colleagues observed
that reductions in tariffs across forty-four low- and middle-income countries were
associated with an increase in imports of sugar-sweetened beverages (SSBs); an increase
in imports, in turn, was associated with greater sales of SSBs (Lopez et al. 2017). Whilst
these associations do not prove causation, the authors conclude that it is highly likely
that reduced tariffs promote higher consumption of SSBs, and that targeted, non-
discriminatory taxes are important tools for addressing the adverse impacts of free trade
agreements on health.
The growth in markets that contribute to NCDs points to an important area of schol-
arship that investigates how countries can exercise the health sovereignty that is required
to implement effective preventative policies whilst avoiding challenges under trade and
investment agreements (Thow and McGrady 2014; Voon and Mitchell 2014; Voon 2013).
Australia’s experience defending a complaint about its tobacco plain packaging legisla-
tion (Permanent Court of Arbitration 2015) and Uruguay’s experience defending a
complaint about national legislation mandating large-sized health warnings on tobacco
packages and restrictions on tobacco brand variants (International Centre for Settlement
of Investment Disputes 2016) illustrate the willingness of tobacco multinationals to
challenge legislation that threatens tobacco sales and profits. The fact that Australia and
Uruguay were both successful is a substantial victory for public health, but still only part
of the story. Defending ultimately baseless claims is expensive; the need to do so provides
an object lesson for risk-averse, resource-poor governments. Small countries are at a
particular disadvantage.
Pacific Island countries and territories (PICTs) reflect the dire health consequences
of the global trade in processed foods, tobacco, and increasingly, alcohol. In Fiji and
Samoa, trade liberalisation policies included winding back export taxes, import tariffs,
and import substitution policies. In combination with the influence of direct foreign
investment, export promotion (cash cropping, resulting in reduced subsistence farming
and cultivation of traditional food crops), and disaster food aid, these policies led to
increased consumption of refined cereals, meats, fats, oils, and processed foods (Thow
et al. 2011; Snowdon and Thow 2013). Emblematic of the discipline that trade and
630   Roger Magnusson

investment agreements can exercise over national policies was the requirement for
Samoa to reverse its ban on fatty turkey tails as a condition of its accession to the World
Trade Organization (WTO 2011; Thow et al. 2017).
PICTs are now in the grip of an NCD disaster (Magnusson and Patterson 2015).
Combined rates of overweight and obesity in some PICTs exceed 80 percent: Tonga,
86 percent; Samoa, 84 percent; and Kiribati, 79 percent (Ng, Fleming, et al. 2014). In a
number of PICTs, around one-third of the population has diabetes (Tokelau, 37 percent;
Federated States of Micronesia, 35 percent; and Marshall Islands, 35 percent; Chan et al.
2014). Some PICTs spend a substantial share of their national health budgets paying for
their citizens to access dialysis in third countries. Other PICTs have world-leading
smoking rates; for example, in Kiribati, over 54 percent of men and 31 percent of women
are daily smokers (Ng, Freeman, et al. 2014). In Samoa, daily smoking in males fell from
76 percent to 36 percent over the period 1978–2013, yet remains nearly three times as
high as smoking rates in Australia and New Zealand (Linhart et al. 2017). In addition to
NCDs, many PICTs face a rising burden from injuries, often linked to alcohol consump-
tion, and a lingering burden of communicable diseases, creating a crippling ‘triple
burden’ of disease.
The Pacific NCD crisis leads to the second point about the global rise of NCD risk
factors. NCDs are a major driver of inequality, both within and between countries. For
example, a report from the Council on Foreign Relations (2014) demonstrates that
NCDs are rising faster in younger populations in low- and middle-income countries
than they are in high-income countries, exacerbating health inequalities. Between
1990 and 2010, DALYs from all NCDs rose by 9 percent in high-income countries and
18 percent in upper-middle-income countries, but by 38 percent and 42 percent in
lower-middle-income and low-income countries, respectively (Council on Foreign
Relations 2014,11).
Similar themes emerge from A Race Against Time (Leeder et al. 2004; Harikrishnan
et al. 2014), which assessed the likely future of CVD in the BRICS countries (Brazil,
Russia, India, China, and South Africa). The authors demonstrate how significant
increases in population in these countries, particularly in the working-age population
(ages thirty-five to sixty-four), combined with modest increases in rates of CVD risk
factors in these populations, will create a crippling burden of future disease. Until around
2025 there is a window of opportunity, whilst the population is younger overall and the
number of dependents per working adult is lower, to implement population-wide pre-
ventative measures, strengthen health systems, treat NCDs cost-effectively, and cope
with growing demand (Raymond 2003). Failure to do so will cause significant economic
harm by undermining future productivity, especially amongst the rising middle class of
skilled workers who are expensive to train. Emblematic of the future economic challenge
of NCDs is the global rise of diabetes, expected to increase from 382 million people in
2013 to 592 million by 2035 (Guariguata et al. 2014).
NCDs also exacerbate health inequalities within countries. There is increasing evidence
that NCDs and their risk factors occur at higher rates amongst those with lower levels of
 Non-Communicable Diseases   631

income and education (Sommer et al. 2015; Di Cesare et al. 2013; Vellakkal et al. 2013;
UNDP 2013) and are a driver of poverty in low-income settings (UNDP 2015; Engelgau
et al. 2011, 28–31). For example, when people smoke and drink, this dissipates household
income (Barber, Ahsan, Adioetomo et al. 2008). The percentage of income diverted can
be substantial, reducing spending on necessities like food, education, and healthcare
(Block and Webb 2009). High out-of-pocket fees may be required for treatment and
medications for NCDs, especially in countries without a healthcare safety net. Illness
also creates opportunity costs, forcing income earners out of work or obliging children
to assume carer roles, interrupting schooling and perpetuating the poverty cycle.

The Challenges of Building a Global

Movement for Action on NCDs

In the early years of the new millennium, academic papers and WHO reports began
to signal the significance of NCDs as a development challenge (Beaglehole and Yach
2003; Strong et al. 2005; WHO 2005a). NCDs were not included in the Millennium
Development Goals (MDGs), the United Nations (UN) development blueprint for
2000–2015, rendering them less visible and excluded from MDG budgets. NCDs were
also competing with established priorities, including maternal and child health, HIV, TB,
and malaria (Morrison 2011). Until 2005, mortality rates from HIV/AIDS were still
rising (IHME 2016, 27–28), whilst in 2007–2009, the global financial crisis shrank the
budgets of both developing countries and their development partners.
Nevertheless, the news was not all bad. The World Bank’s influential report Curbing
the Epidemic (1999) made the economic case for tobacco control and came at a crucial
time, as negotiations commenced for a Framework Convention on Tobacco Control
(FCTC). It is worth pointing to elements already in place by the time FCTC negotiations
began: a high-level program on tobacco control within WHO and its regional offices
(the Tobacco Free Initiative); the Ad Hoc Interagency Task Force on Tobacco Control,
which coordinated work on tobacco control within the UN system; a global civil society
movement for tobacco control (the Framework Convention Alliance); and through part-
nership with the US Centers for Disease Control and Prevention, the beginnings of the
Global Tobacco Surveillance System (WHO 2009a). The WHO FCTC was adopted by
the World Health Assembly in 2003 and entered into force on February 27, 2005.
However, a variety of factors stood in the way of a broader, collective response to
NCDs that extended beyond tobacco control. NCDs were a ‘slow motion disaster’ (Chan
2011), yet unlike HIV/AIDS, they were not seen as an infectious threat inflicting imme-
diate and indiscriminate harm on young and old (Morrison 2011). NCDs were caused
by behavioural risk factors—smoking, drinking, eating—feeding the assumption that
lifestyle modifications, education, and personal responsibility were the appropriate
632   Roger Magnusson

interventions. Although public health scholars might regard diet-, alcohol-, and
tobacco-related NCDs as ‘industrially created’ epidemics (Moodie et al. 2006; Malone
2010; Stuckler and Nestle 2012; Moodie et al. 2013; Stuckler et al. 2012; Wiist 2011), the
multiple determinants of diet-related NCDs and the long period of exposure and con-
sumer behaviour preceding them tended to cloud assumptions about causality and
attribution of responsibility (Maher and Sridhar 2012, 4). This benefited, and continues
to benefit, the food and beverage industries.
Scholars have pointed to the way in which neo-liberal ideology frames public health
challenges as predominantly individualistic concerns, privileging lifestyle-related inter-
ventions and health promotion over the adoption of healthy public policies by govern-
ments (Ayo 2012). An excessively individualist perspective, in turn, has a distorting effect
on one’s understanding of public policy, feeding the assumption that a ‘public health
response’ can only mean appealing to individuals to consciously take steps to reduce their
personal risk. Neo-liberalism’s key tenets (including minimal government intervention,
anti-welfarism, extreme deference to markets, and personal responsibility), and its success
in shifting public responsibilities from the public to the private sphere (Clarke 2004),
remain a formidable threat to global progress on NCDs in the future.
Despite these challenges, the lead-up to the UN General Assembly’s High-Level
Meeting on the Prevention and Control of Non-communicable Diseases in 2011 saw
significant progress in making the economic case for governments to implement a core
set of cost-effective policies for prevention and treatment (Beaglehole et al. 2011; WHO
and World Economic Forum 2011; World Bank 2011; WHO 2010a, 2011). This work was
driven by academic networks (reflected, for example, in the Lancet’s series on chronic
diseases, and later obesity), and by publications from WHO, later the World Bank, and
other partners.
WHO estimated the cost of a basket of interventions to reduce tobacco use and
harmful use of alcohol and to improve diet and physical activity levels at 4 percent of
current health spending in low-income countries, 2 percent in lower-middle-income
countries, and < 1 percent in upper-middle-income countries (WHO 2011). The inten-
tion was to illustrate that solutions to NCDs exist, and with collective commitment, are
within reach of all countries. The identification of feasible solutions was critical, given
claims about the scale of the NCD crisis. NCDs were responsible for over 60 percent of
global deaths in 2005, according to WHO, with an expected 17 percent increase by 2015
(WHO 2005a). NCDs were not a new problem in health development; they were health
development. NCDs might have merited a fundamental rethinking of the conceptual
framework for DAH; the more immediate problem, however, was to get NCDs on the
agenda at all.
Despite growing understanding of the reality of the problem and the existence of
plausible policy responses, scholars point out that public policy change is not a purely
rational process. An important literature identifies critical features that influence
whether evidence translates into political action (Clarke, Swinburn, and Sacks 2016;
Cullerton et al. 2016; Shiffman and Smith 2007; Huang et al. 2015; Baker et al. 2017;
 Non-Communicable Diseases   633

Knaggård 2015). At the global level, these features include the incentives and mandates
of actors (including governments, donors, and global institutions), access to global
forums for mobilising political support, the existence of coalitions pressing for change,
power relations between actors, and other factors that make up what is often called the
‘policy context’ (Geneau et al. 2010).
Prior to the high-level UN meeting in 2011, the major forum for global action on
NCDs was the World Health Assembly (WHA). WHO’s response was dominated by
risk-factor-specific strategies: the WHO Framework Convention on Tobacco Control
(WHO 2005b) and a number of non-binding instruments. These included the Set of
Recommendations on the Marketing of Foods and Non-alcoholic Beverages to Children
(WHO 2010b) and the global strategies on infant and young child feeding (WHO
2003a); diet, physical activity, and health (WHO 2004); and harmful use of alcohol
(WHO 2010c). The exception was the 2008–2013 action plan for prevention and control
of NCDs (WHO 2009b), now replaced by the 2013–2020 action plan (WHO 2013a). Both
documents collated evidence; stated the case for action; and identified actions for mem-
ber states, the WHO Secretariat, and international partners.
Throughout the MDG era, NCDs compared poorly to HIV/AIDS in terms of the ability
of advocates and affected communities to project them as an issue of health justice. This
remains a substantial obstacle to global advocacy efforts. The element of outrage that
was crucial to mobilising political action on HIV/AIDS is largely absent. Today’s NCD
advocates point to the social determinants of health inequalities but tend not to burst
onto the stages of national and international conferences, drowning out the voices of
politicians and transforming technical issues into visceral, political demands. The NCD
Alliance, representing the major NCDs, including CVD, cancer, diabetes, and respiratory
diseases, was formed prior to the 2011 high-level meeting. However, patients were ‘not
present as a core social or political base’ (Morrison 2011).
In explaining why NCD advocates have struggled to get their message across, Maher
and Sridhar (2012) refer to Shiffman’s (2009) explanation of why some global health
issues attract attention whilst others languish. For social constructionists like Shiffman,
global health problems like HIV, polio, or NCDs do not have any inherent priority or
significance; rather, the attention an issue receives, whilst not unrelated to underlying
material conditions, is ‘always mediated by social interpretations’ (Shiffman 2009, 608).
From a social constructionist perspective, the ‘core activity’ of global health advocates
is ideational: health advocates must advance truth claims about the problem and its
solutions that resonate with the values and shared interpretations of political leaders
and those who control resources. In this view, global health is a competitive (and brutal)
process of ‘portraying and communicating severity, neglect, tractability and benefit in
ways that appeal to political leaders’ social values and concepts of reality’ (Shiffman
2009, 610). Moreover, the key to sustaining issue ascendancy lies in the creation of for-
malising institutional arrangements that assist in mobilising resources, implementing
programs, and sustaining the way in which the issue is framed and portrayed. For example,
in the case of HIV/AIDS, a success story in global health advocacy, political priority
634   Roger Magnusson

is both reflected in and sustained by global institutional infrastructure, including the

United Nations Programme on HIV/AIDS (UNAIDS), The Global Fund to Fight
AIDS, Tuberculosis and Malaria, and the US President’s Emergency Plan for AIDS
Relief (PEPFAR).
In applying these insights to NCDs, Maher and Sridhar point out that NCD advocacy
has been dominated by technical considerations—generating good data and credible,
cost-effective solutions—as if these were enough to unlock wallets and galvanise polit-
ical commitment. NCDs have been a ‘case study in poor branding’, they argue, since
the frames that have predominated in making the case for the importance of NCDs
lack salience, or a sufficient connection with people’s lives (Maher and Sridhar 2012, 4;
Shiffman 2009, 609). The preoccupation with generating credible data may reflect a
certain defensiveness in the face of the vastly superior resources and capacity of the
tobacco, alcohol, food, and drink industries to peddle misinformation. But it has come
at a price. The NCD movement lacks frames of reference to which people can relate in
emotional terms. Whilst this does not imply that NCD advocates should somehow seek
to replicate the gaunt-faced young men and babies who shaped perceptions of AIDS in
the 1980s, the underlying issue remains. Allen points out, ‘Photographs of middle-aged
obese smokers suffering from (what are perceived as) self-inflicted health conditions do
not naturally arouse charitable sentiment’ (Allen 2016).
Added to this is the term itself. NCDs is not only a movement defined by what it is
not: diseases that are not communicable. It is also a movement framed by a label that
denies the key message that might help to generate priority—that is, the fact that the risk
factors for these diseases are both socially communicable and transmitted globally to
vulnerable populations for the sake of profit (Maher and Sridhar 2012, 4; Allen 2016).
The challenges of creating a global movement for NCDs should not overshadow
what has been achieved. In terms of actors, the Caribbean Community (CARICOM)
deserves special credit for its strategic advocacy for NCDs. This includes the CARICOM
heads of government meeting on the impact of NCDs in the region, which led to the
Port-of-Spain declaration (CARICOM 2007) and subsequently to the Communiqué by
Commonwealth Heads of Government, which called for a global summit on NCDs
(CHOGM 2009). In 2010 the UN General Assembly adopted a resolution tabled by
Trinidad and Tobago scheduling the high-level meeting on NCDs in September 2011
(Hassell and Hennis 2011).
In the end, the declaration from the high-level UN meeting was significant in con-
firming NCDs to be a ‘challenge of epidemic proportions’ and in acknowledging the
­primary role and responsibility of governments in meeting the challenge (UNGA 2011).
Overshadowing the importance of the declaration itself, however, was the fact that
the meeting constituted a change in the locus of governance. Since 2011 NCDs have
become a shared responsibility of WHO, the UN General Assembly, and other will-
ing partners. The declaration recognised that effective action on NCDs requires a
whole-of-government response, with shared responsibility across ministries, sectors,
and levels of government, as well as a whole-of-society effort, requiring effective engage-
ment with civil society, the private sector, and academia.
 Non-Communicable Diseases   635

Progress in the Global

Response to NCDs since
the High-Level UN Meeting

The high-level meeting of the UN General Assembly in 2011 was the first time that
NCDs reached the agendas of heads of state. The significance of this political opportun-
ity, however, depended on the capacity of the UN system to institutionalise NCD
­prevention and control within the broader UN development agenda (Alleyne, Stuckler,
and Alwan 2010).
This chapter presents a simple framework for taking stock of global action on NCDs
since the 2011 high-level UN meeting. The framework highlights some of the pathways—
both used and neglected—through which global actions can lead to improvements in
national health outcomes. These pathways include the development of (1) normative
instruments and policy guidance and (2) political accountability mechanisms by global
institutions, and (3) the provision of economic and material support for implementation
of policies and programs by globally significant donors (see table 32.2). Other pathways,
such as the strategic use of public communications and the media, and capacity-building
—particularly in the use of law and regulation to implement priority policies for NCDs
(Magnusson, McGrady, et al. 2019), are not discussed in detail in this chapter.

Normative Instruments and Policy Guidance

Normative global instruments include recommendations, guidelines, codes of conduct,
strategies, action plans, and status reports; these are typically the product of evidence
gathering and consultation processes and are intended to encourage legislative, execu-
tive, and political actions by countries. Much of WHO’s leadership prior to and since the
high-level UN meeting in 2011 has focused on generating a suite of normative documents
that is intended as a catalyst and resource for national action. In the case of the WHO
FCTC, parties have assumed a legal obligation to implement national policies and laws
that comply with its requirements. In most circumstances, however, normative instru-
ments are ‘soft power’ instruments that assist countries in identifying national priorities
and implementing effective policies. Supported by WHA and UN General Assembly
resolutions, the implementation of policy recommendations is one of the most obvious
ways that the work of these forums translates into changes at the country level.
The most significant global normative instrument on NCDs is WHO’s (2013a) Global
Action Plan for Prevention and Control of NCDs 2013–2020, adopted by the WHA in 2013.
Appendix 3 of this document, updated and endorsed by WHA in 2017, identifies a menu
of policy options for governments, including a subset of highly cost-effective ‘best buys’
(WHO 2017a). Other influential documents include the Report of the Commission on
Ending Childhood Obesity (WHO 2016a), the Report of the WHO Independent High-
Level Commission on NCDs (WHO 2018a), the revised ‘Global Strategy for Women’s,
636   Roger Magnusson

Table 32.2 Framework for Analysing How Global Actions in Health May
Influence National Actions
Pathway Global Actions, Activities, Processes Intended Impact at National
Level

Normative and legal Adoption of treaties, conventions → Legal and normative pressure
instruments Resolutions of international for domestic policy change
organisations (WHA, UNGA) Better understanding of the
Normative international instruments case for policy action, better
(‘soft law’), including global strategies knowledge about policy
and action plans, recommendations, options and policy priorities

→ Greater political commitment

guidelines
Political accountability Goals, targets, indicators, timelines,
mechanisms especially when supplemented by and pressure on national
periodic reporting requirements governments to implement
(to the UNGA, WHA, etc) effective policies
Partnerships between key actors, Improved capacity for policy
including UN agencies, governments, action at national level
private funders, INGOs
Accountability mechanisms used
by civil society organisations

→ Material resources for

(e.g., indexes, shadow reports)
Economic support and Development assistance in health:
incentives provision of direct economic and programs and initiatives
material support Economic pressure for policy

→ Greater capacity for imple-

Funding conditionalities actions at national level
Capacity-building Coordination of training, mentoring
and capacity building; sharing good mentation of recommended
practises and facilitating access to policies and law

→ Normative pressure for global

information
Less formal pathways Advocacy by champions in civil
society and private sector and national policy change
Popular movements in civil society
Media campaigns mobilising
popular opinion

Children’s and Adolescents’ Health (2016-2030)’ (WHO 2017b), and the ‘WHO Global
Action Plan on Physical Activity 2018–2030’ (WHO 2018b).
Although not focused specifically on NCDs, the reports of the special rapporteurs on
the right to health and the right to food reflect additional sources of normative guidance
that are conceptually aligned although poorly integrated with WHO guidance. The his-
torical roots of the right to food (found in article 11 of the International Covenant on
Economic, Social and Cultural Rights, ICESCR) lie in hunger alleviation, through access
to ‘sufficient, nutritionally adequate and safe’ food (ECOSOC 1999). However, the Special
Rapporteur on the Right to Food, appointed by the Human Rights Council under the
special procedures mandate, has emphasised the need for an enabling environment that
 Non-Communicable Diseases   637

promotes sustainable diets and addresses all dimensions of malnutrition: inadequate

calories, micronutrient deficiencies, and overconsumption of nutrient-poor food, lead-
ing to obesity (de Schutter 2014a). In particular, this requires strengthening of local food
systems and a new framework for trade and investment in agriculture, together with
national laws and policies for better nutrition (de Schutter 2014b). These broader impli-
cations of the right to food are reflected in the emerging right to ‘food and nutrition
security’ (de Schutter 2014a; Ayala and Meier 2017).
The right to health is also found in the ICESCR (article 12) and in a range of other global
and regional human rights instruments (WHO 2017c). The special rapporteur on the right
to health has emphasised the links between unhealthy foods and NCDs, urging greater
transparency in the negotiation of trade and investment agreements and arguing that
the duty imposed on states to protect the enjoyment of the right requires them to regulate
food industry practises that encourage unhealthy diets and harm health (Grover 2014).

Political Accountability Mechanisms

The convening role of deliberative bodies such as the WHA and UN General Assembly
creates a range of opportunities for exerting political pressure and seeking to hold coun-
tries to account for their policies and actions. The drafting and adoption of resolutions,
as well as the process of agenda-setting and prioritising of issues for open discussion,
may exert political pressure on countries. Global targets and reporting processes play
an important role, as discussed in this chapter. In some circumstances, civil society
organisations may exert political pressure through participation in global processes. For
example, in the case of UNAIDS, civil society organisations may contest ‘official’ country
statements and file shadow reports in circumstances where they were not adequately
consulted during the process of preparing national reports (UNAIDS 2017).
Since the high-level UN meeting in 2011, the most substantial achievement of the
WHA and UN General Assembly in fostering greater political accountability has been
the adoption of global goals and targets and creation of global reporting mechanisms.
Three distinct processes are distinguished here, reflecting the migration of NCDs as an
issue of concern into the wider UN system.
First, in 2012 WHA adopted an overall target of a 25 percent reduction, by 2025, in
premature mortality from CVD, cancer, diabetes, and chronic respiratory disease. The
following year it adopted eight additional voluntary goals addressing specific risk factors
(see table 32.3). These nine global goals, together with twenty-five indicators, make
up WHO’s global monitoring framework for prevention and control of NCDs (WHO
2013a, appendix 2).
Second, monitoring and institutional frameworks have emerged to support the UN
General Assembly’s involvement in NCDs. At the high-level meeting of the UN General
Assembly in 2014, heads of state agreed to a number of time-bound commitments.
Summarized in table 32.3, these include the obligation, by 2015, to consider setting
national targets and process indicators for 2025, as well as multisectoral policies to
638   Roger Magnusson

Table 32.3 Global Targets for Reductions in NCD Risk Factors

Comprehensive global monitoring Overall target:

framework, including 9 voluntary By 2025, a 25% relative reduction in mortality from cardiovascular
global targets for prevention and disease, cancer, diabetes, and chronic respiratory diseases in
control of NCDs (WHO) persons aged 30–70.
Eight supporting targets:
10% relative reduction in harmful use of alcohol;
10% relative reduction in prevalence of physical inactivity;
30% relative reduction in mean average population salt intake;
30% relative reduction in prevalence of tobacco use
(persons 15 + years);
25% relative reduction in raised blood pressure;
0% increase in diabetes and obesity;
50% coverage for drug therapy and counselling for those at risk
for cardiovascular disease; and
80% coverage of affordable technologies and essential
medicines for treating NCDs in both public and private facilities.
Sustainable Development By 2030, reduce by one-third premature mortality from
Goals: Target 3.4 (UN General non-communicable diseases through prevention and treatment
Assembly) and promote mental health and well-being.
Time-bound commitments Four time-bound targets:
made by heads of state at the By 2015, consider setting national targets for 2025 and process
2014 High-Level Meeting of the indicators based on national situations, taking into account the
UN General Assembly on NCDs 9 voluntary global targets for NCDs (adopted by the World
Health Assembly in 2013).
By 2015, consider developing or strengthening national
multisectoral policies and plans to achieve the national targets
by 2025, taking into account WHO’s global action plan on
prevention and control of NCDs.
By 2016, as appropriate, reduce risk factors for NCDs and
underlying social determinants through the implementation
of interventions and policy options to create health-promoting
environments, building on the guidance in appendix 3 of the
global action plan (menu of policy options and cost-effective
interventions).
By 2016, as appropriate, strengthen and orient health systems
to address the prevention and control of NCDs and underlying
social determinants through people-centred primary healthcare
and universal coverage, building on the guidance in appendix 3
of the global action plan.

achieve them (UNGA 2014). By 2015, 138 countries had shown ‘very poor’ or no progress
in meeting these commitments (WHO 2017a).
WHO developed a separate monitoring framework, comprising ten indicators, for
the purposes of its report to the UN General Assembly in 2017, ahead of the 2018
high-level meeting on progress achieved under the UNGA process (WHO 2015b). These
indicators track countries’ progress in setting national targets, developing a multisectoral
 Non-Communicable Diseases   639

national action plan, and implementing a range of WHO-recommended policies relating

to prevention and treatment.
The adoption of the sustainable development goals (SDGs) by the UN General
Assembly in September 2015 represents a third set of targets and reporting processes
for NCDs. The SDGs comprise aspirational targets for global development for all
countries for the period 2015–2030, irrespective of income level. The SDGs contain an
ambitious target for NCDs: ‘By 2030, reduce by one third premature mortality from
non-­communicable diseases through prevention and treatment and promote mental
health and wellbeing’ (UNGA 2015). The three reporting systems have different time-
lines, and in the case of the SDGs, extend well beyond NCDs.
In addition to targets and monitoring systems, the development of governance struc-
tures is a vital part of global efforts to strengthen political accountability for action on
NCDs. Governance mechanisms help to institutionalise NCDs within the work pro-
grams of global institutions and to coordinate strategic leadership, which is vital when
leadership is diffused or shared.
In 2013, on the recommendation of the UN General Assembly, the UN Social and
Economic Council (ECOSOC) established the United Nations Interagency Task Force
on NCDs (UNIATF), with the role of coordinating and strengthening the efforts of UN
and intergovernmental agencies on NCDs (ECOSOC 2013; WHO 2017d). UNIATF is
led by WHO. Its terms of reference set out a division of responsibilities between UN and
other entities, with the goal of strengthening national, regional, and global action plans
for prevention and control of NCDs, including through exchange of information about
best practises in health promotion, legislation, regulation, and health systems strength-
ening (WHO 2015c).
Separate from UNIATF is the Global Coordinating Mechanism for Noncommunicable
Diseases (GCM/NCD), established in 2013 by WHO (WHO 2013b). GCM/NCD provides
a platform for collaboration amongst WHO member states, UN agencies, other inter-
governmental partners, and nonstate actors, including civil society organisations and
academic and select private sector entities. Its goal is to enhance collaboration across
sectors at national, regional, and global levels, whilst safeguarding WHO and public
health processes from conflicts of interest (WHO 2013b, 2014). Working groups have
been established in five areas, in accordance with the GCM/NCDs workplans. GCM/
NCD also hosts dialogues, as well as an expanding set of online communities of practise,
including in NCDs and health literacy; NCDs, health, and law; and multisectoral action
on NCDs (WHO 2017e). The development of regional counterparts to the GCM/NCD
and to UNIATF provides the opportunity to further institutionalise NCDs within regional
development organisations (such as the Pacific Community and the African Union) and
to strengthen links with national aid programmes.
A final achievement worth mentioning is the high-level meetings of the UN General
Assembly themselves, held in 2011, 2014, 2018 with a fourth scheduled for 2025. All three
meetings have provided a focus for advocacy, an opportunity for expressions of political
commitment at the highest level, and political declarations that re-state the challenge,
and set out commitments for the future (WHO 2018c).
640   Roger Magnusson

Economic and Material Support for Policy Implementation

Global targets and governance structures play a role in raising the political priority of
NCDs in countries; normative instruments identify cost-effective policies that govern-
ments can implement. Economic support and technical assistance are the critical link
between knowledge and action. In low-income countries, they provide the material and
human resources that make actions at the country level possible. But here the narrative
breaks down. Despite knowledge about the health impacts of NCDs, donors have been
unwilling to direct substantial resources to this area.
An important lesson from HIV—with which NCDs share many similarities—is that
progress is more likely when countries integrate policies for both prevention and treat-
ment, whilst also addressing the social impacts of illness, including discrimination against
people with diabetes and other NCDs (Magnusson and Patterson 2014). Experience
with HIV suggests that the availability of treatment, including secondary prevention
medications for major NCDs like coronary heart disease, stroke, and diabetes, will call
attention to the importance of prevention. This is partly because the lifestyle changes
that are required to reduce risk factors, or to prevent disease progression, benefit from
peer education and personal testimony by those already affected. In the case of secondary
prevention for the diseases mentioned, treatment literally is prevention, whilst con-
versely, population-wide prevention policies can reduce the economic burden of
treatment costs (e.g., smoke-free laws may lead to substantial, rapid declines in medical
facility admissions for heart attacks and asthma; Faber et al. 2017; Capewell and
O’Flaherty 2011; Been et al. 2014; Sims et al. 2010).
The fact that lack of investment in prevention will increase the costs of treatment,
whilst lack of investment in treatment may undermine the effectiveness of prevention,
suggests that careful thought should be given to the mix of policies and programs that
are implemented with the scarce resources that are available. Bonita and colleagues
argue that countries with the least resources should focus on developing their human,
financial, and regulatory capacity in order to implement a limited set of cost-effective
interventions in a step-wise manner: tobacco control measures, reduction in population
salt intake in order to lower blood pressure, and multi-drug treatment for those who
have had or are at high risk of having a heart attack or stroke (Bonita et al. 2013).
If the future of NCDs in low-resource countries depends largely on ‘self-help’, then
capacity building and the development of human resources will be crucial. Many of the
priority, cost-effective interventions recommended by WHO are regulatory in character,
requiring fiscal policies by governments (e.g., raising taxes), and implementation of
legislation, regulations, executive orders, or decrees (Magnusson and Patterson 2014;
Gostin et al. 2017). One measure of success in raising the political profile of NCDs
through global governance mechanisms such as UNIATF and GCM/NCD will be
greater demand for technical assistance in implementing cost-effective national policies
for both treatment and prevention. However, WHO’s lack of control over three-quarters
of its total budget renders it ‘miserably under-resourced’ to respond to country requests
for assistance (Mendis 2016). Encouraging funders to grasp the vision required to
 Non-Communicable Diseases   641

develop a next-generation network of practitioners with expertise in cost-effective

‘best buys’, including regulatory and legal measures, remains an important challenge for
this generation (Ruchman, Kishore, Singh 2016).

Contesting Policy: Industry Fights Back

Any review of NCDs and global health politics must acknowledge the reality of ideo-
logical and industry-led resistance to many of the policies that could most help to ease
the burden. A growing literature documents the strategies that the tobacco, alcohol,
food, and sugary drinks industries use to resist the implementation of policies that could
threaten their economic interests. They include formal submissions to governments,
direct lobbying of government ministers and bureaucrats, corporate social responsi-
bility (CSR) campaigns, philanthropy, funding and control of research, disinformation,
advertising, the development of (weak/permissive) voluntary codes and standards, and
industry-funded and industry-friendly front groups (Malone 2010; Zeigler 2010; Wiist
2011; Mindell et al. 2012; Jernigan 2012; Dorfman et al. 2012; Yanamadala et al. 2012;
Moodie et al. 2013; Savell, Fooks, and Gilmore 2015; Mialon, Swinburn, Wate, et al. 2016;
Mialon, Swinburn, Allender, et al. 2016; Wilson and Roberts 2012; Martino et al. 2017).
At the global level, political activity by the tobacco, alcohol, food, and sugary drinks
industries poses risks to the integrity of the technical and normative guidance produced
by WHO and to the collective willingness of countries to fulfill their commitments under
global accountability mechanisms. For example, in 2003 WHO published a technical
report on diet, nutrition, and the prevention of NCDs that included a recommendation
to limit free sugar intake to no more than 10 percent of daily energy intake (WHO 2003b).
In response, the US Department of Health and Human Services produced a detailed cri-
tique that an article in the New York Times described as ‘blatant pandering to American
food companies that produce much of the world’s high-calorie, high-profit sodas and
snacks’ (Brownell and Nestle 2004). Before and after the publication of this report, the
sugar industry and its allies lobbied the US Secretary of Health and Human Services to
withdraw US funding from WHO (Norum 2004). A concerted attempt to weaken WHO’s
global strategy on diet, physical activity, and health followed (Norum 2004). Although
adopted by WHA in 2004, this strategy document omitted any reference to the 2003
technical report and its proposed limit on free sugars (Norum 2004). In 2015 WHO
reiterated its recommendation on free sugars, citing links between free sugar intake,
obesity, and dental caries. This report included a conditional recommendation to reduce
free sugar intake below 5 percent of total energy intake (WHO 2015a).
The efforts of the sugar lobby illustrate the importance of protecting the development
of national policies, as well as the integrity of core global health functions, including
evaluating evidence, and developing guidance, from vested economic interests (Buse,
Tanaka, and Hawkes 2017). This challenge persists, not only with food and nutrition
(WHO 2016b), but also with tobacco control, an area where conflicts of interest might
be considered most apparent (WHO 2008a).
642   Roger Magnusson

For example, in 2017 the Foundation for a Smoke-free World was launched, with a
promise of funding of US$80 million per year for twelve years from tobacco giant Philip
Morris International (PMI). The aims of the foundation are to ‘advance smoking cessation
and harm-reduction science and technology’ (Foundation for a Smoke-free World 2017).
Although ostensibly independent, the activities of the foundation appear to depend on
discretionary annual or periodic funding renewal by a tobacco multinational. Although
the foundation does not yet have a record of advocacy or research, PMI would clearly
benefit from third-party advocacy to remove the ban on e-cigarettes and heated tobacco
products in jurisdictions where they are prohibited (such as Australia) and to reverse
the trend towards applying smoke-free laws to both combustible and non-combustible
products seen in jurisdictions including California and New York. California, which has
raised the minimum purchasing age for cigarettes to twenty-one years, applies the same
requirement to e-cigarettes (California Senate Bill No. 5, 2015–2016). Whatever its activ-
ities, it is difficult to see how the Foundation can avoid performing a valuable public
relations function for its economic parent. That function is damaging to global
tobacco control efforts, since for all its talk about ‘smoke-free futures’ (Horne 2017),
PMI continues to behave as a regular tobacco multinational, exploiting the opportun-
ities provided by jurisdictions tobacco control laws and enforcement capacity are
weak (Kalra et al. 2017).
This leads to a final point about the role of industry in pushing back against policies
and accountability mechanisms that put profits at risk. Private regulatory instruments—
including voluntary pledges, codes, and guidelines—are a familiar response to NCDs,
ostensibly governing industry conduct in areas such as alcohol advertising, food label-
ling, and food reformulation. In Western democracies, scholars have argued that global-
isation and the impact of neo-liberal policies have had a destabilising influence on the
capacity and/or disposition of the state to regulate. This is seen in the dismantling of
welfarist policies and in a retreat from—or in the privatisation of—what might once
have been considered state functions (Clarke 2004). Regulatory scholars have referred
to the current era as one of ‘regulatory capitalism’: its key features include growing cor-
poratisation and privatisation; the diffusion of regulatory power amongst private, state,
and nonstate actors; and the emergence of new, hybrid regulatory instruments (Levi-
Faur 2005; Black 2001). This subcontracting out of regulatory functions by the state to
industry has obvious implications for the diffusion of NCD risks and requires a broader
framework for understanding how governments and corporate actors can be held to
account (Swinburn et al. 2015; Stevenson 2015).

Opportunities for Accelerating Progress in the Global

Response to NCDs
NCDs are now a visible part of the agenda for WHO and the UN General Assembly, and
UN agencies are getting involved through shared UN structures such as UNIATF. On
the other hand, it is far from clear that WHO or UN agencies have the political clout
 Non-Communicable Diseases   643

to meaningfully influence global policies on trade or agriculture, or to achieve greater

accountability by multinational corporations (Buse, Tanaka, and Hawkes 2017). As far
as DAH is concerned, resources have not followed the evidence, whilst at the national
level, the implementation of recommended policies is obstructed by the food, alcohol,
processed food, and sugary drinks industries and their allies.

Reform of Global Governance Structures

Some scholars have argued that only new, legally binding instruments, such as frame-
work conventions on global health (Gostin et al. 2013), alcohol control (Sridhar 2012),
and obesity and healthy diets (World Obesity 2014), can address root causes and create
the necessary momentum. Others have argued for reform of the political structures for
health governance. Mackey and Liang (2013) proposed a high-level panel on global
health, to be created by UN General Assembly resolution and chaired by WHO, with
a mixed membership made up of UN agencies, funding agencies, NGOs, industry entities,
and states. Supported by a technical group, the panel’s roles would include resource
mobilisation and global agenda setting through recommendations to UN agencies,
including WHO itself. Nishtar (2017) proposed a multistake holder NCD-focused body
to engage with the private sector and encourage innovative funding mechanisms.

Using Existing Structures More Effectively

Even in the absence of new conventions or fundamental institutional changes, oppor-
tunities may exist to make better use of existing governance structures. For example,
human rights scholars argue that global actors, including WHO and UN entities, should
make greater use of human rights instruments and the existing UN human rights system.
This could include framing policy actions for improving diets and nutrition in terms of
the human right to health and to food and strengthening global monitoring and enforce-
ment mechanisms (Ayala and Meier 2017). Although the right to food and nutrition is
missing from the SDGs (Pol and Schuftan 2016), human rights are an important part
of the political conversation in many countries, especially those where health-related
rights are recognised in national constitutions (Heymann et al. 2013). The Committee
on Economic, Social and Cultural Rights (CESCR) within the UN Economic and Social
Council could assist this process by updating and revising the ‘General Comment on the
Right to Adequate Food’ (ECOSOC 1999) in order to clarify its full conceptual scope.
Scholars have also argued that the human rights system could require greater account-
ability from countries regarding implementing their obligations under the WHO FCTC.
For example, Cabrera and Gostin (2011) argue that the FCTC functions as a standard for
gauging whether states are discharging their obligations to respect, protect and fulfill
the right to health, and that the Committee on Economic, Social and Cultural Rights
(CESCR), as the treaty body monitoring the implementation of the right to health, should
644   Roger Magnusson

take the opportunity to recognise this relationship more explicitly, especially in periodic
country reviews. Similarly, Toebes and colleagues argue that the individual complaint
procedure in the Convention on the Rights of the Child provides a potential means of
redress against countries’ failure to consider the best interests of children in setting
domestic tobacco control laws, whilst also supporting efforts to raise tobacco taxes, imple-
ment minimum purchasing age restrictions, and other controls (Toebes et al. 2018).

Public-Private Partnerships
A very different prescription for advancing progress on NCDs comes from scholars who
argue that governments should engage in smart partnerships with industry, in order to
make better use of their market power and technological know-how.
There is a credible consensus, reflected in article 5.3 of the WHO FCTC and in the
Guidelines for Implementation of Article 5.3, that there is an ‘irreconcilable conflict
between the tobacco industry’s interests and public health interests’ (WHO 2008a). The
tobacco industry is not a public health stakeholder (Novotny 2013). The guidelines on
article 5.3 recommend that parties to the FCTC interact with the tobacco industry only
when strictly necessary in order to regulate it, reject partnerships and non-binding
agreements with the tobacco industry, and not accept voluntary codes or instruments
drafted by the tobacco industry as a substitute for legally enforceable tobacco control
measures (WHO 2008a).
However, this consensus is less evident with alcohol and is particularly controversial
with ‘big food’. There is ongoing debate in the literature about whether and under what
conditions the food industry might be an appropriate partner in reducing NCD risk
factors (Yach et al. 2010; Yach 2016; Stuckler and Nestle 2012; Gilmore, Savell, and Collin
2011; Brownell 2012; Kraak et al. 2011; Johnston and Finegood 2015; Bryden et al. 2013;
Stevenson 2015). Opportunities clearly exist for ‘big food’ to voluntarily reduce diet-related
harm through product reformulation, portion resizing, and ceasing the shameless
promotion of unhealthy food to children (Ng, Slining, and Popkin 2014). However, the
‘opportunity costs’ of prioritising partnerships over regulation are less visible. Could
greater progress have been achieved if governments had not delegated regulatory
control to industry or given implicit concessions to industry in return for some degree
of industry cooperation or forbearance?
Although debate often reflects a contest between the merits of voluntarism (self-­
regulatory codes, public-private partnerships) and regulation (mandatory standards,
legislation), the deeper issue is about results, secured by robust accountability mechan-
isms for evaluating performance (Sharma, Teret, and Brownell 2010; Swinburn et al.
2015). This is one reason the adoption of national goals for improvements in risk factors
for NCDs is so important (Magnusson 2017). Where results are not achieved, govern-
ments need to be willing to scale up their level of involvement and to consider regulation
(Reeve and Magnusson 2015). For example, clear targets and timeframes, independent
monitoring, media pressure, and sustained political pressure on industry were all
 Non-Communicable Diseases   645

central to the relative success of the UK government’s voluntary approach to reducing

salt levels in processed food, begun in 2003 (He and MacGregor 2015).

Progress in the Absence of Fundamental Reform

Current challenges for global health, including lack of global enforcement mechanisms,
WHO’s increasing reliance on extra-budgetary funding, and the lack of accountability
of health-harming industries, did not arise by accident. Ultimately they reflect the col-
lective will of UN member states not to resource health adequately or to give it priority
in global affairs. Although routinely castigated, WHO deserves credit for what has been
achieved: a set of voluntary global targets for measuring progress, an evolving UN
mechanism for global monitoring, structures for coordinating cross-sectoral action
with UN agencies as well as with nonstate actors, and the development of a significant
body of normative guidance. An important question arises: Even in the absence of
fundamental reform, are there opportunities for strengthening global action on NCDs?
The answer is yes. First, at the global level, the NCD silo must be broken down.
Actions to strengthen prevention and improve treatment of NCDs must be identified
and integrated within national strategies for poverty reduction, advancing universal
health coverage, and advancing towards the SDGs. Areas of overlap between NCDs
and universal health coverage include improving care models to promote continuity
of care, improving affordable access to essential medicines, developing the NCD
workforce, supporting technologies and strategies for better self-care, and ‘provider
payment systems that reward prevention and the maintenance of wellness’ (Cassels
2015). Action on climate change could also benefit significantly from NCD-informed
policies; a growing literature addresses the opportunities and synergies (Watts et al.
2017; Friel et al. 2011; Lowe 2014; Carlsson-Kanyama and González 2009; Wilson and
Edwards 2008).
Whilst better results depend on integrating action on NCDs through a wide variety of
global programmes, ironically, the political priority that NCDs need to achieve in order
to do this successfully will almost certainly require a higher degree of NCD exceptional-
ism than exists at present. Whilst this does not imply a UNAIDS style of body, high-level
institutional machinery—something more exciting than the UNIATF—is likely
required to drive work forward between high-level UN meetings.
Second, decisive global action on NCDs will not happen until there is greater demand
for action by countries, pushed in turn by civil society. This requires emotion, an ingre-
dient conspicuously missing from the NCD narrative. As a global movement, NCD
activism needs a vision for health justice, not just technical facts. It needs moments of
outrage. Capturing them requires civil society organisations and academia to document
evidence of predatory corporate practises and other injustices and their impact on
children, women, vulnerable minorities, and health inequalities. The challenge is to
‘transform data into moral arguments’ (Smith, Buse, and Gordon 2016), to ‘give the people
who suffer most a face and a voice’ (Chan 2017).
646   Roger Magnusson

A welcome starting point is the Advocacy Agenda of People Living with NCDs, devel-
oped by the NCD Alliance following a global consultation process (NCD Alliance 2017).
Key messages in the agenda include the call for an ‘urgent and fundamental shift in the
NCD response’ to ensure ‘meaningful involvement’ of people living with NCDs in pro-
gramme development, implementation, policymaking, and accountability processes at
national and global levels. Human rights and social justice lie at the core of the ‘priority
asks’ outlined in this document. The Advocacy Agenda calls for high-quality care for
those with NCDs; the right to be treated with respect by healthcare providers; actions to
address discrimination, stigma, myths, and fears about NCDs; and improved accessibil-
ity of public transport, work, and public spaces for those with disabilities.
Third, countries and regions may find it helpful to appoint rapporteurs on NCDs:
respected, self-driven champions with the capacity to capture media attention, to motiv-
ate and strengthen civil society networks, to challenge and ‘call out’ business, and to lead a
national conversation towards greater accountability. These roles will not be easy, but the
concepts and language of human rights are an important ally; they frame action on NCDs
as an entitlement, an obligation of governments: an issue of health justice (IDLO 2015).
Global and national action on NCDs, no less than universal health coverage, must be
‘struggled for and won by social movements’, since it is unlikely to be ‘spontaneously
bestowed by governments’ (WHO 2008b, 25). Packages of accountability measures must
be tailored to each issue, and one size will not fit all (Swinburn et al. 2015).
Access to NCD medicines is not a bad starting point. For example, access to afford-
able blood-pressure-lowering medicines remains dire in low- and lower-middle-income
countries. Attaei and colleagues found that in their study of drug availability in 626
communities, only 13 percent of community pharmacies had all four blood-pressure
lowering drugs in stock, and 75 percent of households in low-income countries were
unable to afford the cost of the two lowest cost blood-pressure-lowering medicines, plus
the lowest cost statin (Attaei et al. 2017). NCDs are a new front for activism about access
to medicines; people ought not to miss out on the medicines needed to keep them alive
or to risk catastrophic expenditure securing access.
Fourth, smaller countries and economies, such as island states in the Pacific, Caribbean
and Indian Oceans and some African countries, could consider strategic coordination
through a regional approach. This could extend to the development of shared, regional
human resources and development of common policies and legislation, including in the
areas of trade and agriculture (Magnusson and Patterson 2015; Magnusson 2017).
Fifth, many of the evidence-based ‘best buys’ recommended by WHO (2017a) are
not expensive and could be implemented in a step-wise fashion where appropriate
national plans, cross-sectoral structures, and capacity are in place. The investment
needed to develop national or regional capacity in robust, regulatory measures for
tobacco, alcohol, and healthy diet is modest (Bonita et al. 2013; Colagiuri et al. 2015).
Targeted investment in these areas by development partners makes sense and could be
made sustainable by revenue-raising policies, including raising taxes on tobacco, alcohol,
and sugary drinks.
 Non-Communicable Diseases   647

Sixth, change is coming. Mexico’s experience with a sugary drinks tax (Cochero et al.
2017), Australia’s experience with tobacco plain packaging (WHO 2016c), South Africa’s
experience setting maximum salt levels for thirteen food categories (Republic of South
Africa, Minister of Health 2016), and Denmark’s limit on industrially produced trans fats
(Downs, Thow, and Leeder 2013) are all examples of novel measures that are spreading
internationally. When national governments are unable to act, opportunities may exist
for regional, city, and local governments, as illustrated by Michael Bloomberg’s pioneer-
ing initiatives as Mayor of New York City (Gostin 2013).
A final issue worth returning to is the misleading nature of the term non-communicable
diseases itself. ‘Prevention and control of NCDs’ has become recognised code for work
relating to four major diseases (CVD, cancer, diabetes, and chronic respiratory diseases)
and their societal, behavioural, and physiological risk factors. Allen and Feigl (2017)
argue that a ‘longwinded non-definition’ is unlikely to attract funding and harms pre-
vention efforts by conveying the message that the causes of NCDs are ‘individual rather
than societal’. Far from holding the tobacco, alcohol, food, and beverages industries to
account for shameless profiteering at the expense of global health, the very term suggests
that individuals with NCDs have ‘done it to themselves’.
Unfortunately, an alternative term that would capture the complex global causes of
NCDs and their risk factors and resonate with funders, patients, and politicians has
proved elusive. The message to be conveyed is that NCDs are chronic and often insidious
conditions whose prevalence reflects trends in underlying risk factor patterns, as medi-
ated through commercial, physical, policy, and social environments (Ezzati and Riboli
2013). Ackland and colleagues advocate the term transmissible chronic diseases (Ackland,
Choi, and Puska 2003).

Conclusion

NCDs are a group of diseases with interrelated risk factors underpinned by expanding
global markets for unhealthy products. They reflect a darker side of globalisation. In the
absence of the global outpouring of emotion that characterised the response to HIV/
AIDS, the global response to NCDs has tended to be technical. WHO has advocated
cost-effective policies and established monitoring mechanisms. However, resources to
support implementation in low-income countries, and shared learning, have not mate-
rialised. Since 2011, the locus of governance of NCDs has moved beyond WHO towards
the wider UN system. NCDs now have a place within the UN development agenda,
although WHO’s coordinating role remains central.
Whilst there is no single silver bullet for NCDs, that does not mean there are no bullets
at all. At the global level, universal health coverage and the SDGs provide conceptual
frameworks and reporting structures for engaging governments and measuring pro-
gress. At the national level, the priority is to make NCD risk factors and diseases
648   Roger Magnusson

­ utcome measures for interventions across a range of sectors. Success will be reflected by
o
the insertion of action on NCDs within national development plans (Cassels 2015). For
smaller countries, regional action could accelerate the rate of change.
Without action, national economies will underperform, dependency rates will rise,
and life expectancies may literally shrink. Taking action brings its own risks. Addressing
conflicts of interest will be a constant challenge at all levels, as profitable industries seek
to nurture cozy relationships with politicians, talking up the contribution of business
without addressing fundamentals. For example, if the world’s largest brewer can con-
vince governments it is a credible partner for advancing global efforts to reduce harmful
alcohol use (SDG target 3.5) using its ‘Global Smart Drinking Goals’ as a framework for
action (Taylor, Nalamada, and Perez 2016, 43–44), how likely is it, really, that governments
will fully implement WHO’s global strategy on harmful alcohol use (WHO 2010c)?

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 chapter 33

The Politics of
Gl oba l Tobacco
Con trol

Kelley Lee

There is arguably no anomaly so enduring in public health as the long-standing battle

for effective tobacco control. It is frequently noted that if cigarettes were invented today,
tobacco companies would not be legally permitted to sell them as a ‘fast-moving consumer
good’, given their lethal nature (Tiffin 2015). Prematurely killing half of regular smokers,
tobacco use has been the leading cause of preventable deaths worldwide for decades. In
2018 tobacco use caused around seven million deaths globally, a sharp rise from three
million deaths in 1994 (Peto, Lopez et al. 1996). Cumulatively, one hundred million
deaths were caused by tobacco use over the twentieth century; this is expected to rise to
one billion deaths over the twenty-first century (WHO 2008).
Efforts to control the production and consumption of this ‘noxious weed’, as King
James 1 described tobacco in 1604, began from its introduction into Europe from the
Americas during the fifteenth century. Over the next four hundred years, tobacco use
remained a controversial habit for moral, economic, and cultural reasons. Historians
document tobacco as being central to colonisation from the sixteenth century, the slave
trade from the seventeenth century, creation of the corporation during the nineteenth
century, and the rise of mass consumerism during the twentieth century (Gately 2001;
Brandt 2007).
Scientific evidence of the adverse health effects of tobacco use began to accumulate
during the nineteenth century, but it was an epidemiological study by Doll and Hill (1954)
that definitively linked smoking to lung cancer. An initial decline in smoking rates
prompted by this research was reversed by the industry’s introduction of ‘filtered’ cigarettes
to allay health concerns. The 1964 US Surgeon General’s Report on Smoking and Health
(US Surgeon General, 1964) confirming the health risks proved a more significant turning
662   Kelley Lee

point (Cummings and Proctor 2014). A mountain of scientific evidence has since been
published on the adverse first-hand (direct), second-hand, and even third-hand health
effects of tobacco use. And yet despite irrefutable evidence, tobacco use has continued
apace and may even still be rising worldwide.
This chapter argues that any explanation for the persistent and widespread use of
tobacco despite abundant scientific evidence of its deadly effects must locate politics
at the heart of the story. On the one hand, tobacco is now among the most regulated of
consumer products in most countries. On the other hand, it has taken more than sixty
years since Doll and Hill’s study to reach what remains an uneven patchwork of regu-
lation across jurisdictions. Tobacco products continue to be sold, legally and illegally,
in vast quantities worldwide. Cigarette retail sales in 2017 totalled US$700 billion
(Campaign for Tobacco Free Kids 2018), earning downturn-busting dividends for
shareholders of leading transnational tobacco companies (TTCs) of US$19 billion
(Davies 2017).
The hard-fought politics of ‘regulation, taxes, and litigation against tobacco compa-
nies’ (Studlar 2002, 17) across a diverse range of national contexts is well-documented
(Studlar and Cairney 2014; Cairney and Yamazaki 2017). There are illustrative case stud-
ies and comparative analyses of why, for example, ‘governments take particular actions’
and why ‘some levels of government have been more restrictive in tobacco control in
each country’ (Studlar 2002, 17). Building on this important work, the purpose of this
chapter is to extend analyses of the politics of tobacco control to the global level. How
have political conflicts between a highly profitable industry and public health advocates
played out above the level of the state in recent decades? What strategies have they pursued,
and to what effect, and what does this tell us about the contemporary nature of global
health politics?
To answer these questions, this chapter is organised into three broad periods. First,
the shift by leading tobacco companies from the 1960s, from largely domestic to regional
and global firms, is briefly described. This shift, and the consequent rise in tobacco-related
disease and death within targeted markets from the 1980s, prompted new concerns
within the public health community. Second, an analysis of the politics surrounding the
negotiation of the Framework Convention on Tobacco Control (FCTC) from the 1990s
to mid-2000s is presented. The emergence of a global tobacco pandemic prompted pub-
lic health advocates to seek to shift tobacco control from a long-neglected issue focused
on changing individual behaviour to a high-priority challenge requiring collective
action through global health governance (GHG). Third, the shifting political strategies
by industry and public health advocates since the FCTC came into force in 2005 are set
out. Far from ending political battles, adoption of the treaty shifted the terrain of con­
test­ation back to signatory states. Moreover, public criticism and new measures under
FCTC Article 5.3 to prevent industry interference in health policy led the industry to
rehabilitate its public reputation by engaging in research and policy on the illicit trade
and harm reduction.
 Politics of Global Tobacco Control   663

Globalisation of the Tobacco

Industry: The Emergence of a
Commercially Driven Pandemic

The adoption of stronger tobacco control policies in the United States following the US
Surgeon General’s (1964) report marked an important turning point in public attitudes
towards smoking, prompted by a tipping point in the volume of scientific evidence
about the harmful health effects of tobacco use. The decline in smoking rates that fol-
lowed, despite industry denials of the evidence, prompted leading cigarette manufactur-
ers to expand their markets beyond the United States, initially focused on Latin
America. As Shepherd (1985) describes, new markets were essential to compensate for
declining sales in ‘traditional markets’. Whilst leading cigarette manufacturers were
already operating worldwide beginning in the early twentieth century, the strategy was
to grow these foreign markets as a much larger part of their business.
By the 1980s the spread of neoliberalism and economic globalisation enabled a second
wave of expansion. Pressured by the US Trade Representative, who faced ‘intensive
lobbying efforts’ (Webb 1988) from the US Cigarette Export Association, several Asian
countries were forced to open their cigarette markets (Chantornvong and McCargo
2001; MacKenzie, Lee, and LeGresley 2016). The ending of the Cold War in the early
1990s and the collapse of the Soviet Union brought further expansion into Eastern
Europe (Gilmore and McKee 2004). This was followed by fierce competition among
leading tobacco companies to grow larger by gaining market access and share in the
Middle East and Africa (Nakkash and Lee 2008). As Philip Morris International (PMI)’s
president described to the company’s board of directors:

1990 is the beginning of what will undoubtedly be a decade of great change for our
business. The political and economic restructuring of Eastern Europe, the realisa-
tion of a Single Market in the EEC, the move towards free market economies in
Latin America, and the lowering of trade barriers throughout Asia, are major events
which are reshaping the world we do business in. These developments are providing
very substantial opportunities in the tobacco industry and we are moving quickly to
exploit them. (Buzzi 1990)

In the late 1990s mergers and acquisitions concentrated ownership of cigarette manu-
facturing (excluding China) in the hands of a small number of TTCs led by PMI, British
American Tobacco (BAT), Japan Tobacco International (JTI), and Imperial Tobacco.
The expansion of TTCs into ‘emerging markets’ raised alarm bells among public
health advocates. Historically, international cooperation on tobacco control was given
relatively low priority. At the first World Conference on Tobacco and Health (later
664   Kelley Lee

Tobacco or Health) in 1967, national delegations focused on reviewing scientific evidence

on the harmful health effects of smoking and on sharing information on tobacco control
policies. In 1970 the WHO director-general presented a report to the World Health
Assembly (WHA) on ‘the limitation of smoking’, calling, inter alia, for member states to
end cigarette advertising and promotion. This was accompanied by the adoption of a
resolution on the ‘health consequences of smoking’, which called on member states to
refrain from smoking at WHA meetings, discourage smoking among young people, and
urge the Food and Agriculture Organization (FAO) to study crop substitution for
tobacco-growing countries.
The limited scope of these initial international efforts was mirrored in the small size,
limited budget, and low status of WHO’s Tobacco and Health Unit, formed in 1990. As
former staff member Neil Collishaw describes, ‘I was . . . involved in documenting the
scale of the tobacco epidemic, and . . . preparing publications . . . .We did all this on a
shoestring budget’ (as quoted in Boucher 2000). Low resourcing was due in large part to
the policy of zero real growth in WHO’s regular (assessed) budget, adopted in 1981 with
the support of the Geneva Group (largest financial contributors to the United Nations
system). The group included the US government, which considered adoption of the
Model List of Essential Medicines in 1977 and the International Code of Breastmilk
Substitutes in 1982 a ‘politicisation’ of WHO’s mandate (Lee 2008). This began a shift
towards funding a greater proportion of WHO’s total budget by extra-budgetary (volun-
tary) contributions, which donors could earmark for specific purposes. As Vaughan
et al. (1996) report, donors preferred to fund such areas as communicable disease out-
breaks and emergency response, whilst other areas including chronic health conditions
received limited donor support. Moreover, the dominant public health narrative for
tobacco control was ‘lifestyle diseases’, attributable to the ‘risky’ behavioural choices
of individuals. This apportioning of cause to individual behaviour in turn cast
tobacco-attributable morbidity and mortality as somehow self-inflicted. Given the dom-
inance of this narrative, donor funding to support tobacco control remained very limited.
Consequently, the Tobacco and Health Unit’s work focused on collecting data on
tobacco use and its health consequences from member states. Even this purpose proved
challenging given that few countries collected national data. The lack of standardised
methodology also prevented collection of aggregate and comparative data to accurately
measure the global scale of the problem. The limited evidence base in turn made it diffi-
cult to argue that tobacco control be given higher international priority. A Philip Morris
(PM) document on ‘The Activist Movement’ described the Tobacco and Health Unit’s
role as ‘[e]ssentially a “public relations” function’ and WHO’s effectiveness as limited:

[I]n light of its poor funding arrangements, the WHO cannot be looked upon as the
powerhouse for smoking control around the world. The monies it does have available
are basically ‘seedcorn’, to provide the framework and climate through the media for
the growth of smoking control strategies in the Member States. (PM 1996)
 Politics of Global Tobacco Control   665

Reframing the Issue: Arguing the

Need for a Framework Convention
on Tobacco Control

The population health impacts of the tobacco industry expansion worldwide led to rec-
ognition within the public health community of the need for a new approach focused on
mobilising political support and strengthening the evidence base as political strategy.

Mobilising Political Support for an International

Legal Framework
Efforts to shift policy focused on two key ideas: (a) to broaden the emphasis from
changing individual behaviour to addressing the social determinants of tobacco use,
including the key role of the tobacco industry; and (b) to extend policy and action from
the local and national levels to the global level. A 1988 WHO report, ‘Smokeless Tobacco
Control’, illustrated the tension between traditional approaches and the new challenges
faced. Whilst the report expressed alarm at ‘the well financed, highly sophisticated mar-
keting programmes that transnational tobacco manufacturers have recently initiated in
order to promote smokeless tobacco worldwide’, the actions it recommended were seen
as the responsibility of national governments:

Countries with a history of smokeless tobacco use were urged immediately to insti-
tute aggressive regulatory and educational programmes to combat it, whilst those
with no recent history of such use were urged to ban the introduction of the various
products or any other new form of tobacco in order to prevent the spread of the
smokeless tobacco epidemic. (WHO 1988)

The limitations of national-level action alone were raised at the World Conference on
Tobacco and Health in 1990, which excluded industry representatives for the first time.
Many attendees called attention to the ‘financial and political clout’ of ‘multinationals’ in
the developing world, and that they were ‘engaged in a global war’ against a ‘ruthless
industry’ (Crofton 1990, 560). Growing coordination among nongovernmental or­gan­
iza­tions (NGOs), such as the international information network Global link, formed by
the American Cancer Society, was encouraged.
The idea of WHO creating an international legal framework to advance tobacco con-
trol was revived during this period. Drawing comparisons with the law-making efforts
of the International Labour Organization, International Maritime Organization, and
666   Kelley Lee

most notably, UN Environment Programme (i.e., 1992 UN Framework Convention on

Climate Change), American legal scholar Allyn Taylor argued that

other international organisations have at times been able to overcome member

nations’ resistance and promote legal institutions effectively without becoming
political battlegrounds. The comparison to other international organisations sug-
gests that WHO’s lack of legal initiative cannot be attributed exclusively, or even
predominantly, to the global political process. (Taylor 1992)

Taylor partnered with law professor Ruth Roemer to promote the idea of an inter­
nation­al legal framework at the First All-Africa Conference on Tobacco or Health in
1993, co-chaired by Derek Yach (South African Medical Research Council) and Timothy
Stamps (Zimbabwean Minister of Health). Roemer also discussed the idea with senior
WHO staff and with tobacco control advocates at the American Public Health Association
annual meeting the same year (Roemer, Taylor, and Lariviere 2005). As Yach (2005)
recalls, the idea then began to gain wider traction:

The idea would again have remained dormant, but the Canadian government, together
with a group of NGOs, then raised it in 1994 at the World Conference on Tobacco or
Health [WCTOH]. The Canadian government held a number of initial meetings in
1995-1996 which led to a resolution of the World Health Organization Executive
Board [EB] in 1996, saying that this is something that needs to be worked on.

EB and WHA resolutions adopted in 1995 requested the director-general to report ‘on
the feasibility of developing an international instrument’ (WHO 1995). A background
paper commissioned from Taylor and Roemer met with resistance from some WHO
officials, who supported a non-binding code or a treaty under the auspices of the UN.
Nevertheless, EB and WHA resolutions adopted in 1996, championed by Jean Lariviere
(Canada), Kimmo Leppo (Finland), and John Hurley (Ireland), called upon WHO to
develop the FCTC. The decision to negotiate this particular type of legal instrument,
which sets out principles and norms under which international action can proceed,
along with procedures for negotiating more detailed arrangements (protocols) on specific
issues, was a politically considered one. Based on the experience of the UN Framework
Convention on Climate Change (and Kyoto Protocol), it was envisioned by WHO
advisers that the main agreement would embody broad principles for international
cooperation, thus minimising contentiousness and maximising adoptability by a higher
number of member states.
This vision of treaty-led collective action on tobacco control was substantially
boosted by the election of Gro Harlem Brundtland as WHO director-general. Upon
assuming office in 1998, Brundtland created the Tobacco Free Initiative (TFI) as one of
two cabinet initiatives (along with Roll Back Malaria) and tasked Yach, as its inaugural
director, to shepherd the FCTC process. According to Yach (2005):

The most important thing was having Brundtland come in and think very deeply
during her transitional period about the kind of problems that would attract
 Politics of Global Tobacco Control   667

international support to the agency. . . . The FCTC was born out of the recognition
that even if countries adopt the best national policies, they would still be subject to
considerable cross-border advertising, marketing and other international influences.
A treaty therefore was thought to be the best means of both galvanizing global sup-
port for tobacco control in general, but more specifically to address the cross-border
and transnational aspects of tobacco control.

Strengthening the Evidence Base as Political Strategy

With high-level WHO commitment to the FCTC achieved (WHO 1996), it was recog-
nised that broadening political support among member states ahead of formal ne­go­ti­
ations was needed. One means of achieving this goal was to strengthen the evidence
base. WHO officials began improving the quality of national-level (and aggregated
regional and international) data on tobacco use and its health impacts. This was a chal-
lenging task given the long-standing neglect of the issue and varying capacity in mem-
ber states to collect reliable public health data. Nevertheless, global adult and youth
surveys using standardised methodologies allowed WHO to report the scale of the
problem. As surveys were repeated, trend data became available for the first time, reveal-
ing which populations needed particular support.
In addition to new evidence about the public health importance of the problem,
WHO changed the way causal factors of tobacco use were described. For instance, Yach
and Bettcher (2000) drew attention to the links between globalisation and tobacco con-
trol. Others used language reminiscent of communicable disease outbreaks, referring to
the ‘global tobacco pandemic’ and to the industry as the ‘vector’ (analogous to mosquitoes
and malaria) to be controlled. As well as appealing to the funding preferences of donors,
new evidence and how it was framed sought to shift the prevailing view of tobacco
harms as self-inflicted by weak-willed individuals to a powerful addiction created by
powerful commercial interests operating on a global scale. To counter this narrative, the
tobacco industry argued that tobacco control was a low priority in the developing world
compared to HIV and AIDS (Smith and Lee 2016) and liver disease (Muggli et al. 2008).
As described in a BAT document, ‘to maximise the impact of . . . alternative proposals for
sensible regulation’, the strategy would be to claim ‘first world, Anglo-Saxon and English
speaking political economies are fuelling the debate and in many cases driving the polit-
ical agenda within the WHO. Most third world countries have other priorities but are
not able to resist the pace, drive and political dynamics which are moving the FCTC
forward’ (Vecchiet 2000, 2).
Public health and industry advocates also did battle using economic data. Historically,
governments have refrained from stronger tobacco control based on arguments of the
sector’s economic importance. Recognising the World Bank’s influence among finance
ministers, TFI worked closely with bank officials to publish new data on the net eco-
nomic costs to societies from tobacco use, including healthcare costs, opportunity
costs, lost productivity, and fire. New evidence of net gains through increased tobacco
taxes was also generated (Jha and Chaloupka 1999). The strategic purpose of these
668   Kelley Lee

economic data was to broaden support for the FCTC within governments beyond
­ministries of health.
TTCs recognised the strategic importance of World Bank support for the FCTC
proc­ess. A BAT (n.d.-b) document acknowledged:

Brundtland has worked hard to end the rivalry which has historically existed
between the WHO and other United Nations organisations. Most importantly the
World Bank published . . . Curbing the Epidemic—Governments and the Economics of
Tobacco Control—an analysis of tobacco use that applies innovative economic theories
to conclude that smoking imposes significant net costs on the world economy. The
report forms the principal economic justification for the WHO’s proposals.

In response, industry representatives reasserted familiar arguments about the economic

benefits generated by the tobacco sector through employment, tax revenues, and exports
(Glantz, Mamudu, and Hammond 2008). BAT (n.d.-a) focused lobbying on member
states where leaf production and manufacturing were particularly important:

[W]e know how the FCTC will be negotiated and we know what countries will be
involved. All end markets have been alerted and key political and legal arguments
have been distributed. . . . British American Tobacco’s response to date has consisted
of attempting to . . . raise awareness of the FCTC’s implications among finance, trade,
agriculture and employment ministers around the world.

The Tobacco Manufacturers Association (2000) reported strategic gains by working

through key constituencies:

The Cigarette Manufacturers’ Association of Pakistan has commented that the

FCTC would reduce government revenue and take away the economic ‘life blood’
for many residents; the Andhra Pradesh Farmers’ Forum of India said elected gov-
ernments, not a foreign agency, should control health measures for its citizens; and
Brazil’s Tobacco Planters’ Associations said 2.1 million citizens depend on tobacco
growing.

Building New Alliances in Support of Global

Tobacco Control
The reframing of tobacco control and the mobilisation of health and economic evidence
proved essential to mobilising allies in support of or opposition to the FCTC. For WHO,
overcoming the long-standing neglect of tobacco control required a broadening of sup-
port. In 1999 TFI formed the Ad Hoc Interagency Task Force on Tobacco Control,
bringing together seventeen UN agencies and two organisations outside the UN system
(ECOSOC 1999). The aim was to address tobacco control not only as a public health
issue, but also as one supporting economic development, child welfare, environmental
 Politics of Global Tobacco Control   669

sustainability, and other policy goals. WHO also recognised the need to face down political
opposition from countries with major tobacco manufacturing or leaf-growing interests
led by the United States. Formally, the US State Department delegated the lead negotiat-
ing role to the Department of Health and Human Services (HHS). In practise, the Bush
administration gave responsibility for developing US negotiating positions to several
federal agencies, including the Treasury, Trade Representative’s Office, and Departments
of Commerce and Agriculture. The HHS did not fare well against these institutional
heavyweights. After the deletion of ten of eleven provisions of the draft treaty as the offi-
cial US position, public health physician and delegation head Thomas Novotny publicly
resigned in 2001 (Kaufman 2001). A close relationship between the German govern-
ment and domestic manufacturers proved a similar obstacle, especially given European
Union member states’ practise of negotiating as a bloc. In Japan, despite support for the
treaty from the health ministry and Japan Medical Association, the government’s stake
in Japan Tobacco International (JTI) led to support for ‘a level of flexibility’ in commit-
ments that, according to Assunta and Chapman (2006), ‘seriously weakened’ the treaty.
China’s position was even more pro-industry given that the state-owned monopoly
generated 9–11 percent of total public revenues (Hu 2013). Countries where growing
tobacco leaf was a major source of income, such as Zimbabwe, Malawi, and Turkey, were
also potential opponents of the treaty. Building support among other member states and
strengthening their capacity to meaningfully participate in each of six meetings of the
FCTC Intergovernmental Negotiating Body (INB) thus became critical. Regional meet-
ings were held prior to each negotiating round, alongside engagement with regional
bodies such as the Group of Latin America and Caribbean Countries and Mercosur
(Mercado Común del Sur). The Southeast Asia Tobacco Control Alliance (SEATCA)
emerged as a supportive coalition. African countries, led by South Africa, also coalesced
into an active regional bloc.
For alliance-building purposes, the appointment of diplomat Celso Nunes Amorim
(Brazilian permanent ambassador to the UN) as INB chair was considered an inspired
choice. As former TFI director Vera Luiza da Costa e Silva (as quoted in Lee, Chagas,
and Novotny 2010) described:

To be a big producer, a big exporter with a strong and influential industry, a big
consumer market of tobacco products—all this pressure in the domestic market
generated by allies of a powerful industry. Yet Brazil actively supported all the
WHO resolutions that led to the creation of the Intergovernmental Negotiating
Body. To be a country subject to all these factors and also able to implement tobacco
control. We were talking at that time of being a model for other countries, mainly
for developing countries to mirror [translated from Portuguese].

Moreover, as a leading emerging economy, Brazilian leadership countered industry

arguments that tobacco control was only a ‘first world concern’. The appointment of a
careful mix of INB vice chairs from the United States, Australia, Iran, India, South Africa,
and Turkey served a purpose.
670   Kelley Lee

Alliance building extended to engaging directly with a broad range of civil society
organisations (CSOs)—consumer groups, women’s organisations, human rights cam-
paigners, and others—as potential tobacco control advocates within member states
(Collin, Lee, and Bissell 2002). New funding was channeled to support their involvement:

Ted Turner had just created the UN Foundation and we were one of the first
recipients of funding. We directed that immediately to create a cadre of NGOs and
sparkplugs in the media around the world using a fairly hard-hitting campaign, one
that WHO had never used before, going explicitly after a corporate sector, which
WHO also had never done before. (Yach 2005)

A critical mass of over two hundred CSOs worldwide then formed the Framework
Convention Alliance (FCA), which played a critical role in lobbying member states.
Recognising their political value, TFI fast-tracked officially recognised status for CSOs
to enable their attendance at negotiations as observers. CSOs played a vital role in sup-
porting smaller delegations by holding briefing sessions on key topics (e.g., illicit trade,
taxation, labelling and marketing restrictions) and was a vital conduit for publicising
progress on negotiations (Collin, Lee, and Bissell 2002). This strategically important
role was even recognised by BAT: ‘The TFI is better organised than the WHO’s previous
tobacco control initiatives. The leadership has effectively mobilised an international
coalition of anti-tobacco advocates and won the pro-active support of national govern-
ments’ (BAT n.d.-b).
Another important strategy was finding allies in other parts of the private sector,
notably the pharmaceutical industry. As Yach (2005) describes, ‘Brundtland was willing
to go to the pharmaceutical and private sectors and make the case that she was not anti-
private sector—as the tobacco industry had painted her—but she was anti-one specific
sector, that is, the tobacco sector’. For this purpose, she launched a European Partnership
Project with Glaxo Wellcome, Novartis, and Pharmacia & Upjohn in 1999 alongside UN
secretary general Kofi Annan’s Global Compact ‘to give a human face to the global mar-
ket’. The partnership’s objective was ‘reducing tobacco-related death and disease among
smokers’ by supporting ‘treatment products against tobacco dependence’ (Brundtland
1999). Announcing this alliance at the World Economic Forum, ‘the foremost global
partnership of business, political, intellectual and other leaders of society’ (World
Economic Forum n.d.), was intended to demonstrate that WHO had powerful allies
within the business community. The move was also intended to marginalise the tobacco
industry within the business community with a clear message that the tobacco industry
was an unacceptable face of the global market.
A final group of key allies comprised legal scholars and practitioners. Taylor, Roemer,
and others contributed critical analyses to support the treaty-making process (Taylor
and Bodansky 1998). The FCTC process also coincided with historic litigation in the
United States, which put tens of millions of pages of internal industry documents into
the public domain. Lawyers from some of these cases became WHO advisers. This
opened up a new field of research that revealed the political and business strategies of
the industry over decades (Ciresi, Walburn, and Sutton 1999). WHO supported access
 Politics of Global Tobacco Control   671

to these documents, which revealed industry efforts to undermine the World Bank’s
report on ‘curbing the epidemic’ (Glantz, Mamudu, and Hammond 2008), IARC research
on second-hand smoke (Ong and Glantz 2000), and the FCTC process itself (Mamudu
Hammond, and Glantz 2008).

Industry Strategies to Delegitimise WHO

Industry advocates recognised that the FCTC process could not be challenged using
previously effective denials of health harms or economic justifications. Instead, as revealed
by a WHO (2000) report, the industry focused on strategically undermining WHO
from within and without:

[D]ocuments show that tobacco companies sought to divert attention from the
public health issues, to reduce budgets for the scientific and policy activities carried
out by WHO, to pit other UN agencies against WHO, to convince developing coun-
tries that WHO’s tobacco control program was a ‘First World’ agenda carried out at
the expense of the developing world, to distort the results of important scientific
studies on tobacco, and to discredit WHO as an institution.

The first task was to play on the industry’s exclusion from formal negotiations on the
basis of evidence of industry interference (Brundtland 2000; WHO/EMRO 2004).
Along with speeches on the need for ‘genuine, constructive engagement with all stake-
holders’ (Brown and Williamson 2000), the industry initiated ‘a campaign aimed at
maximising opposition to the TFI proposals’ (BAT n.d.-a). One tactic was to influence
the composition of selected delegations. Efforts were made to support ministries of
finance, trade, and agriculture as part of the delegations of China, Japan, Malawi, Russia,
Turkey, and other member states where tobacco was an important sector (Mamudu,
Hammond, and Glantz 2008; Wipfli 2015). The industry appealed to economic interests
by claiming the FCTC could disrupt international commerce:

The international tobacco treaty proposed by WHO threatens countless potential

conflicts with the work of international bodies like the World Trade Organization
(WTO) and the World Customs Organization (WCO), as well as that of national,
state, and local fiscal, regulatory, and judicial authorities. . . . The collapse of WTO
negotiations in Seattle last December illustrated the extent to which the WTO
proc­ess has already been taxed by single-issue debates over environment and labour.
A multilateral tobacco agreement would produce another single issue debate and
become an additional source of strain by complicating trade negotiations and
­disputes in areas as diverse as intellectual property, agricultural subsidies, and
technical barriers. (BAT 2000)

A second strategy was to undermine the perceived legitimacy of tobacco control as

an appropriate subject of an international treaty, as well as WHO itself. The FCTC was
initiated during a period of unprecedented criticism of the organisation, under
672   Kelley Lee

Director-General Hiroshi Nakajima (Godlee 1994; Lee 2008). BAT claimed tobacco
control went beyond its historical mandate:

Traditionally, WHO has focused on issues of communicable diseases and public

hygiene. It has not focused on the regulation of products that are deemed to have
health effects. Recognizing these limitations, WHO documents on the tobacco issue
attempt to characterise the voluntary consumption of legal products by adult con-
sumers as a ‘disease’. We should be wary of permitting expansion of WHO jurisdic-
tion based simply on WHO’s willingness to stretch of the concept of ‘disease’.
(BAT 2000)

The industry argued that tobacco control should be a national policy and warned of risks
to state sovereignty from a binding international treaty:

Properly regarded, international agreements are tools for responding to problems

shared by many countries that cannot effectively be dealt with by sovereign govern-
ments acting alone. Problems like transboundary air and sea pollution, protection
of migratory species, international navigation, and elimination of trade barriers simply
cannot be addressed through unilateral action. Tobacco-related issues are different.
They can be addressed at the national level (and even by political subdivisions of a
nation) in a manner consistent with national sovereignty and country-specific policy
choices. That is the level at which, and the manner in which, tobacco issues ought to
be addressed. (Brown and Williamson 2000)

Leading TTCs initiated Project Cerberus to develop ‘non-legally binding principles . . .

sensible, politically feasible and the most workable approach to international and
national tobacco regulation issues’ (Mamudu, Hammond, and Glantz, 2008). Through
these strategies, the industry was able to influence the strength of some of the agreed
provisions despite exclusion from the negotiations. With the desire to make the treaty
palatable to the United States and other opposing countries, negotiators agreed to com-
promises to the final text. Whilst comprehensive in scope, few adopted measures were
made obligatory. According to Assunta and Chapman (2004), this left member states ‘to
decide how far to go in implementing the treaty’.

The Shift to Indirect Political

Strategies: Old Foes, New Issues

The FCTC was heralded as a major achievement in global health diplomacy after com-
ing into force in 2005. Given the long-standing neglect of tobacco control, WHO was
applauded for overcoming powerful vested interests to offer ‘the basic tools for coun-
tries to enact comprehensive tobacco control legislation’ (Assunta, Hammond, Stanton,
and Sullivan 2004). To support parties in fulfilling their obligations, an FCTC Secretariat
 Politics of Global Tobacco Control   673

was established, alongside the governing body of the FCTC, the Conference of the
Parties (COP). Between 2005 and 2018 eight COP meetings were held to play ‘a range
of critical roles . . . setting of normative standards, the building and dissemination of
knowledge, the monitoring of implementation, the facilitation of international co­oper­
ation and the mobilisation of resources to support implementation’ (Liberman 2012).
However, the politics of global tobacco control had entered a new phase. The unex-
pected decision by Brundtland to not seek re-election as WHO director-general and the
departure of Yach (executive director of non-communicable diseases) and Vera Luisa da
Costa e Silva (director of TFI) signaled an internal changing of the guard. The severe
acute respiratory syndrome (SARS) outbreak in 2002–2003; new initiatives such as the
Global Fund to Fight AIDS, Tuberculosis and Malaria in 2002; and emergence of the Bill
and Melinda Gates Foundation as a leading funder drew the attention of the global pub-
lic health community back to communicable diseases (Lee 2008). Funding for FCTC
implementation, and for non-communicable diseases as a whole, remained comparably
low despite accounting for 70 percent of deaths worldwide (WHO 2014).

FCTC Implementation: The Political Terrain

Moves to States
It is in this context that the political focus shifted to the country level, where public
health advocates recognised the need for ‘swift and concerted action to bring the FCTC
into force and ensure that countries implement it to the fullest [without which], there is
a the danger that the treaty will end up as just a well-intentioned effort of interest to
those studying the failure of international negotiations to bring about real improvements
in public health’ (Hammond and Assunta 2003). The initial task of ratification by a
requis­ite forty countries for the FCTC to come into effect suggested the industry had
already shifted attention to member states. In Argentina, for example, Mejia and col-
leagues (2008) describe intense lobbying and strong-arm tactics to delay ratification:

The principal strategy used by the TI [tobacco industry] was lobbying of provincial
legislators and federal officials from the Ministry of the Economy by the tobacco
growers associations. These legislators prevented the passage of comprehensive bills
on tobacco control or of less comprehensive national laws. A typical legislative
strategy used was to request additional analyses of the proposed bills from commit-
tees that prioritised economic issues over health. FCTC was mentioned in regional
newspapers three to seven times per week in articles about alleged adverse eco-
nomic effects of tobacco control. Direct physical threats to legislators who were
openly supportive of FCTC ratification were made.

In Indonesia the minister of industry and trade urged ratification be postponed on the
grounds that it could harm manufacturers and farmers (Anonymous 2004). In Brazil,
whose diplomats prominently chaired FCTC negotiations, the BAT-funded Association
of Tobacco Growers of Brazil lobbied to prevent ratification (INCA 2004).
674   Kelley Lee

As ratification gave way to processes for adopting new national tobacco control
legislation, industry pushed for weakened language to dilute the treaty’s intended
strength. In Ecuador, where PMI dominates 87 percent of the cigarette market, an anti-
tobacco law was adopted in 2006 that was ‘rendered significantly ineffective’ (Albuja
and Daynard 2009). In Lebanon, new tobacco control legislation was narrow in scope
and continually delayed (Nakkash and Lee 2009). In Japan, where the finance ministry
formulated the country’s legislation, new policies were adopted to ban misleading labels
but did not ban tobacco advertising outright (Simpson 2004). The industry also success-
fully pressed for ‘sensible’ and ‘appropriate’ regulation in the form of voluntary codes
rather than binding legislation (Mamudu, Hammond, and Glantz 2008; Glantz,
Mamudu, and Hammond, 2008) and initiated youth smoking prevention programmes
of questionable intent (Assunta and Chapman 2004; Landman, Ling, and Glantz 2002).
Similar industry-led efforts have been documented in Germany (Gruning and
Gilmore 2007), Kenya (Patel, Collin, and Gilmore 2007) and Uzbekistan (Gilmore,
Collin, and McKee 2006).
The capacity of the industry to reassert political influence in low- and middle-income
countries (LMICs) during this period stemmed in large part from the lack of new finan-
cial resources for treaty implementation. The US$10 million Rockefeller Foundation’s
Trading Tobacco for Health Initiative, supporting tobacco control efforts in Southeast
Asia, was a rare exception (Hamann 2000). Canada’s International Development
Research Centre and the UK Department for International Development also provided
small amounts of much-needed funding to LMICs to support tobacco control. A major
boost was received in 2006 with the creation of the US$125 million Bloomberg Initiative
to Reduce Tobacco Use by US businessman Michael Bloomberg, in partnership with
WHO, Campaign for Tobacco Free Kids, and US Centers for Disease Control and
Prevention (CDC), among others (WHO 2006). In 2008 an additional US$500 million
of funding by the Bloomberg Philanthropies and Gates Foundation was announced. The
sums represented the largest donor funding ever available for global tobacco control,
which was initially used in large part to gather baseline and then longitudinal data
through surveys of tobacco use by adults, youth, health professionals, and school person-
nel. The creation of the Global Tobacco Surveillance System (GTSS) led by the US CDC
reinforced the role of data as a vital political tool to press for higher priority for tobacco
control. The data also supported the scaling up of specific FCTC provisions into concrete
actions centred on six proven measures, known as MPOWER (monitor, protect, offer,
warn, enforce, raise) (WHO 2013). Funds helped to support local and regional tobacco
control advocates, such as SEATCA and the Africa Tobacco Control Regional Initiative.

The Political Reinvention of the Tobacco Industry: An

Aspiring Partner on illicit Trade and Harm Reduction
Whilst public health and industry advocates adopted largely opposing positions
regarding implementation of the FCTC, the politics of global tobacco control also saw
 Politics of Global Tobacco Control   675

the emergence of a new political strategy by the tobacco industry during this period.
High-profile litigation, the public release of internal industry documents, and a long
stream of revelations about unethical and in some cases illegal practises left the tobacco
industry at a low point in public reputation. The political influence of the industry
depended on mending its reputation. These efforts focused on two key issues: the illicit
tobacco trade and harm reduction.
The illicit tobacco trade accounts for an estimated 9–11 percent of cigarettes con-
sumed worldwide (FCA 2007). Given the impact of this trade on taxation and pricing
policies, deemed to be among the most effective tobacco control measures, and the
cross-border nature of this trade, the second COP agreed that it would be the subject of
the first FCTC protocol. Negotiations commenced in 2008, and an agreement was
adopted in 2012 that came into force in 2018 after ratification by forty countries. This
prolonged process was in part due to limited expertise within the health sector on an
issue that concerns law enforcement, customs and excise, and other policy areas beyond
health. Given the nefarious nature of the trade, the lack of reliable and comprehensive
data across countries over time also hindered agreement. There was also a lack of con-
sensus on how best to address the problem. Both of these challenges afforded an oppor-
tunity for the tobacco industry to politically re-engage. Despite detailed scholarly
analyses (Collin et al., 2004; Lee and Collin 2006; LeGresley et al. 2008; MacKenzie, Lee,
and LeGresley 2016) and successful prosecution and substantial fining of leading TTCs
regarding their complicity in the illicit tobacco trade (Beelman et al. 2000), the tobacco
industry presented itself as a key partner. Alongside claims that previous practises were
attributable to rogue employees, leading TTCs argued that ‘criminal gangs producing
counterfeit cigarettes, smuggling across borders and engaging in large-scale tax evasion’
(BAT 2018) were harming their commercial interests. Given shared interests in reducing
the illicit trade, the tobacco industry unsuccessfully argued for formal inclusion in
proto­col negotiations.
Excluded from negotiations, the industry turned to indirect strategies of political
influence. One important strategy was to fill knowledge gaps on the illicit trade, which
in turn influenced how the problem was understood and the preferred solutions. For
example, leading TTCs funded studies to measure the volume of the trade and its main
sources. In addition, the industry funded training of local customs and law enforcement
officials, met with government officials, and sponsored meetings hosted by pro-industry
think tanks. In many countries and regions, industry-supported research became the
leading (and even sole) source of information. Through these activities, the industry
was able to portray the problem and potential solutions in ways that served industry
interests (Gallagher et al. 2018). For example, the industry repeatedly attributed the
illicit trade to criminal organisations, indigenous peoples (Smith, Thompson, and Lee
2019), and terrorists despite evidence of its continued complicity (Gilmore, Gallagher,
and Rowell 2018). By focusing on counterfeit cigarettes, leading TTCs also distracted
attention from the substantial smuggling of authentic products, amounting to two-thirds
of the illicit trade and involving ongoing industry complicity. The adoption of the track
and trace system known as Coidentify as the preferred method of tackling the problem
676   Kelley Lee

under the FCTC protocol illustrates the extent to which these strategies have enabled
industry influence. As Gilmore, Gallagher, and Rowell (2018) describe:

Philip Morris International (PMI) adapted its pack marker system, Coidentify, to
meet T&T requirements, licenced it for free to its three major competitors who then
collectively promoted it to governments using front groups and third parties includ-
ing companies claiming to be independent despite clear TI links.

The reinvention of the tobacco industry as a legitimate stakeholder in public policy has
also been an effective political strategy in relation to harm reduction. Harm reduction is
a public health strategy that seeks to lower the health risks to individuals and popula-
tions through a variety of means, including potentially reduced-harm products. BAT
and PMI, for example, have announced long-term business plans to move away from
combustible products and towards new nicotine delivery systems that may pose a
reduced health risk, led by electronic cigarettes and heated tobacco products. Since
2010 leading TTCs have heavily invested in the takeover of independent manufactur-
ers and development of reduced-harm products (Mathers, Hawkins, and Lee 2019). In
2017 PMI announced the creation of the US$1 billion Foundation for a Smokefree
World, led by the inaugural director of the TFI, ‘to raise our ambition for what is pos-
sible and desirable in tobacco control, and specifically in harm reduction from smoking’
(Yach 2017, 1807).
Industry involvement in harm reduction has sharply divided the public health
community. Whilst harm reduction is widely accepted as an important component of
effective tobacco control policies, the extent to which the industry should be included as
a legitimate contributor to harm reduction research and policy products is highly con-
tested. As part of a strategy of ‘building trust for our products through science’, BAT
launched its ‘2018 Harm Reduction Focus Report’, which demonstrates how the com-
pany is ‘committed to transforming tobacco by providing consumers with satisfying
alternatives to smoking’ (BAT 2018). Similarly, PMI Science claims to conduct ‘rigorous
scientific research that is the foundation of PMI’s RRPs [reduced-risk products]’
(Zielinski 2018). Given estimates that whilst 73 percent of regular smokers wish to quit,
only 5 percent succeed without assistance (Etter, Perneger, and Ronchi 1997), supporters
of industry involvement believe that accelerated use of such products will save millions
of lives. In contrast, whilst recognising the importance of harm reduction, opponents
decry the disingenuous nature of industry commitments amid continued large-scale
marketing of combustible products by the same companies. Indeed, challenges to the
adoption of selected tobacco control measures such as plain packaging, raised under
trade and investment agreements, and national legislation show an industry still battling
to sell combustible products (O’Dowd 2018). Similar to policy debates on the illicit
tobacco trade, there is deep distrust of these efforts to repair the industry’s political legit-
imacy. As Peeters and Gilmore (2015, 182) note, harm reduction is ‘an opportunity to
(re-)establish dialogue with and access to policy makers, scientists and public health
groups and to secure reputational benefits via an emerging corporate social responsibility
agenda’.’ BAT’s definition of harm reduction as ‘a well-established public health concept
 Politics of Global Tobacco Control   677

that seeks pragmatic ways to minimise the impact of an inherently risky activity without
stopping it entirely’ (BAT 2018) is seen as reflecting the industry’s ultimate goal of sus-
taining sales by promoting the use, and even ‘dual use’, of conventional and new nicotine
products. PMI’s promotion of a smoke-free, rather than tobacco-free, world suggests a
similar goal.
The politics of global tobacco control, in short, has entered a new phase. The signing
of the FCTC and illicit trade protocol, measures to minimise industry interference
under Article 5.3, and public distrust of tobacco companies were major achievements
for public health advocates. The self-rehabilitation of the tobacco industry and its part-
nerships with parts of the public health community have undermined some of these
successes. Not least concerning have been the deep rifts created by the overtures, backed
by substantial funding, to promote the industry’s research and policy agendas on
selected tobacco control issues. There is also new evidence that the industry redoubled
its work with think tanks (Smith, Thompson, and Lee 2017), chambers of commerce,
academics, consultants, and others to further these agendas worldwide. The US$20 mil-
lion STOP Initiative, announced in 2018 by the Bloomberg Philanthropies, was initiated
as a response to industry interference in global tobacco control. There has also con­
tinued to be a disproportionately low share of resources allocated to tobacco control,
and to non-communicable diseases generally, despite their accounting for more than
half of all deaths worldwide (Benziger, Roth, and Moran 2016). There are continued
efforts to shift attention from individual behaviours to societal-level risks, through such
concepts as the ‘commercial determinants of health’ (Kickbusch, Allen, and Franz 2017).
In this respect, fuller understanding of the politics of global tobacco control has never
been more relevant.

Conclusion

Understanding the long-standing anomaly of the regulatory frameworks governing the

largest preventable cause of death worldwide begins with deeper scrutiny of the politics
of global tobacco control. Initial efforts to bring the lethal effects of tobacco use to the
attention of policymakers focused on the task of assembling scientific evidence. By the
1980s, as an increasingly globalised tobacco industry set its sights on expanding into
emerging markets, it became clear that evidence-based arguments were insufficient. The
political battle that ensued, to initiate, negotiate, and implement the FCTC, was hard
fought. New evidence, generated alongside new allies, was central to WHO’s approach.
Countering familiar arguments of a powerful industry and excluding it from ne­go­ti­
ations and public health policy were critical to advancing the public health agenda. The
industry’s strategic investments in research and policy initiatives since 2005 that sup-
port industry interests, notably on the illicit trade and harm reduction, have begun to
pay political dividends. In this context, maintaining tobacco control as a key global
health priority, and in particular ensuring FCTC provisions are fully implemented,
above all remain a political challenge.
678   Kelley Lee

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 chapter 34

The Politics of
Gl oba l Bioethica l
Fr a m ewor ks

Diego S. Silva and Jeremy Snyder

The globalisation of medical research, health services, knowledge translation, and

other facets of the health sector has led to an interest in articulating ethical norms
that are universal in scope and thus have the potential to apply across these and other
global practises. The United Nations Educational, Scientific, and Cultural Organization
(UNESCO) ‘Universal Declaration on Bioethics and Human Rights’ (UDBHR) (UNESCO
2005), aims to articulate such universal bioethical norms (Trotter 2009). This declaration
stemmed from UNESCO’s mission to describe international standards for the social
and human sciences. Motivated by this mission, UNESCO sought to determine whether
the field of bioethics was subject to universal norms (Snead 2009). From the start,
UNESCO’s General Conference sought a balanced document that sets universal
standards for such concepts as human dignity, freedom, and human rights, whilst
remaining compatible with cultural pluralism (UNESCO 2005).
The UDBHR has been praised for achieving a first step towards the goal of establishing
a minimum standard of ethical conduct for biomedical research and clinical practise
(Andorno 2007). However, it has also come under significant and sustained criticism,
on grounds ranging from whether UNESCO has the jurisdiction to create and promote
such a declaration in the first place to the content of the principles espoused in the dec-
laration (Benatar 2005). The process behind the UDBHR’s development has been cri-
tiqued as well, including concerns that the drafters of the declaration lacked regional
and ideological diversity, legal experts were over-represented relative to bioethicists,
the document lacked philosophical rigour, member states were not properly consulted
during the process of development, the development process lacked transparency, and
686   Diego S. Silva and Jeremy Snyder

the goal of consensus undermined the elaboration of the bioethical principles espoused
(Snead 2009).
In this chapter we discuss the two key political issues raised by the development of
the UDBHR: the legitimacy of this declaration and the universality of its application. We
look specifically at an issue that confronts any attempt to develop a global bioethical
framework: the tension in documenting norms that are applicable universally without
being so minimal in scope or vague in content as to be of little or no use to bioethicists,
health practitioners and advocates, and policymakers. The UDBHR recognises cultural
diversity whilst applying what it purports to be universal bioethical principles. Thus,
determining the legitimacy of the UDBHR depends in part on whether one can balance
the conceptual tension between the idea of cultural diversity (understood as either
pluralism or relativism) and universal moral values and norms.
First, we define key terms to assess the legitimacy and coherence of the UDBHR,
namely universalism, relativism, pluralism, and legitimacy. Whilst these terms are com-
monly used in discussion of the UDBHR and of ethical principles generally, they often
go undefined, creating confusion and discussion at cross purposes. Second, we provide
a brief history of the UDBHR and how it fits with the other international efforts to out-
line ethical principles and procedures for clinical research and healthcare. Third, we dis-
cuss the political questions of the universality of the UDBHR in the context of cultural
diversity, and the legitimacy of UNESCO in advancing it, by closely analysing the text of
the UDBHR. Finally, we outline some future steps that would promote the universality
and legitimacy of the UDBHR. These include adding philosophical rigour to the declar-
ation by making explicit its relationship to the key terms discussed in this chapter.
Moreover, the legitimacy of the UDBHR can be increased by specifying the general
principles contained in it through developing local iterations of the declaration that
appeal to diverse regional, cultural, and ethnic traditions whilst supporting the univer-
sal scope of the UDBHR.

Defining Key Terms

Before discussing the key political issues of legitimacy and universality raised by the
development of the UDBHR, it is important to provide some provisional definitions
of key terms. These remain subject to debate and have been the subject of thousands of
years of analysis. Thus, whilst these definitions provide a clearer sense of how terms are
used in this chapter, we do not purport to provide definitive conclusions about how they
should be best understood. Whilst much more has been written about all four of these
ideas and their histories in political and moral philosophy, this overview should be suffi-
cient for a discussion of the relevance of these concepts to the UDBHR.
First, universalism (in the context of moral and political philosophy) refers to the idea
that certain ethical and political norms apply to all people across all of human history.
For example, the idea that killing is, generally speaking, ethically bad or wrong means that
 Politics of Global Bioethical Frameworks   687

killing is bad or wrong regardless of where in the world one might live and regardless of
the epoch in which one lives. For the sake of clarity, it is important to distinguish univer-
salism from generalism; the latter refers to the extent to which a particular norm holds,
more or less often, and what conditions may come about to serve as an exception to the
general form of the norm, in favour of or against a particular thing. For example, in gen-
eral, killing is bad or wrong, but killing in self-defense is morally permissible (i.e., there
are particular circumstances when the general moral norm does not apply). One can
state that the permissibility of killing in self-defense, and its being an exception to the
rule, hold universally (i.e., regardless of time or geography).
Second, relativism is the idea that moral norms cannot be or ought not to be under-
stood universally. Thus, relativism stands in contrast to the idea of universalism. Two
versions of relativism are most commonly invoked. Cultural relativism is the idea that
norms, including ethical values and norms, are created and can only be understood
in the context of a person’s or group’s culture, and that because there have been many
different cultures across history, there are many different sets of ethical values and
norms that may or may not cohere. Moral (or ethical) relativism is the idea that we ought
not to promote universal moral norms because there are no objective and universal
moral norms. Thus, cultural relativism is descriptive, whereas moral relativism is pre-
scriptive (although it, too, is based in part on a description, namely, the purported fact
that no objective and universal moral norms exist).
Third, pluralism refers to the idea that reasonable people (adopting a common-sense
notion of reasonable, itself open to much debate) will disagree about important meta-
physical or epistemological beliefs, as well as ethical values and norms. Pluralism is
assumed to be a brute reality of living in democracies and a multicultural world. The
challenge is to determine how citizens and residents of democratic states might best
function and interact despite, and potentially thrive because of, pluralism. It is import-
ant to note that pluralism is different from relativism. One may coherently maintain that
there are universal ethical norms, but (a) we cannot agree on their detailed application
in practise (e.g., killing is bad or wrong, but how to apply this rule is open to debate), or
(b) we can agree on a certain subset of moral rules (e.g., appeals to procedural justice or
to acceptance of certain liberal beliefs) so that we can coexist with others who do not
accept our overall set of moral beliefs.
Finally, legitimacy (in the context of moral and political philosophy) refers to the con-
ditions in which an agent x is permitted or obligated to act in manner y, but regardless of
how good or right y is, z is not permitted to carry out y. A classic example is punishment
for a crime. It is generally understood that if a person is found guilty of a crime, for
example assault, the state is the only agent that can legitimately punish the criminal. One
might perhaps argue that the person who has been assaulted may be morally justified in
seeking to punish the criminal or get revenge. However, punishment on the part of private
citizens is generally considered an illegitimate form of redress. Discussion about legit-
imacy, and who constitutes a legitimate actor, when, and under what conditions, has
been a key focal point of twentieth- and twenty-first-century political philosophy, par-
ticularly in the context of democracies that are subject to pluralism. Stated differently, if
688   Diego S. Silva and Jeremy Snyder

one accepts pluralism as true and part of what it means to live in a democratic state, then
understanding the moral and practical complexity of who can legitimately govern, how,
and on what grounds becomes of paramount importance.

A Brief History of UDBHR and

Other Ethics Declarations in
Clinical Research and Healthcare

International bioethics frameworks and declarations (including guidelines and codes)

first focused on the ethics of clinical research. These agreements were reached following
the end of World War II and the Nuremberg trials. As part of those trials, Allied Forces
prosecuted high-ranking members of the Nazi Party, and in 1946–1947 doctors working
under the regime were tried for torture and murder as a result of the experiments they
had conducted. From these trials the Nuremberg Code was developed, which outlines
ten rules that doctors must follow when conducting research, including the need for
voluntary consent of the subject and the avoidance of unnecessary pain or suffering
(Annas and Grodin 2008). In 1948 the World Medical Association (WMA), a physicians’
advocacy group, adopted the Declaration of Geneva, which outlines virtues that doctors
must have and follow whilst practising medicine (e.g., ‘I will practise my profession with
conscience and dignity’) (WMA 2006). Perhaps more notably, the WMA produced the
first iteration of the Declaration of Helsinki in 1964, which outlines the responsibilities
of doctors as researchers. The agreement includes perhaps the first discussion on the
importance of the proportionality of the risks and benefits of research for subjects
(Ashcroft 2008). Following these foundational international research ethics documents,
in 1982 the Council for International Organizations of Medical Sciences (CIOMS)
produced the highly influential ‘International Ethical Guidelines for Biomedical
Research Involving Human Subjects’ (most recently updated in 2016). The CIOMS is a
not-for-profit organisation established by the World Health Organization (WHO) and
UNESCO in 1949 (CIOMS 2016).
For our purposes, it is worth noting that all these declarations and guidelines, either
explicitly or implicitly, provide doctors and the broader medical community with uni-
versal ethical norms, principles, values, or virtues to direct their research and practise.
As such, all these documents must contend with the dialectic between universalism and
pluralism and that of universalism and relativism, whilst also answering questions about
the legitimacy of the organisations and processes that create these declarations and
guidelines. For example, the 2002 revision of the CIOMS guidelines explicitly states that
the ‘challenge to international research ethics is to apply universal ethical principles to
biomedical research in a multicultural world with a multiplicity of health-care systems
and considerable variation in standards of health care’ (CIOMS 2002). The 2016 revision
of the CIOMS guidelines maintains this universalist perspective whilst also implicitly
 Politics of Global Bioethical Frameworks   689

addressing issues of legitimacy by describing the global makeup of the committee that
reviewed and revised the guidelines, its close partnership with WHO, and the efforts at
international consultation (CIOMS 2016).
The history, process, and challenges associated with the drafting of the UDBHR (a
declaration that encompasses not only research but also healthcare practise) are described
elsewhere (Macpherson 2007; Snead 2009; Langlois 2011; ten Have 2016; Stanton-Jean
2016). Briefly, it is worth noting that the drafters of the UDBHR also struggled with
questions about universalism, pluralism, relativism, and legitimacy. Still, some authors
have argued that UNESCO is well situated to lead any attempts at developing a universal
declaration because the bioethics arm of UNESCO brings together the various moral
perspectives of all its members (ten Have 2016) and the UDBHR is seen by the members
of UNESCO itself as articulating merely broad, general principles that are open to future
revision (Stanton-Jean 2016). However, particularly important questions and criticisms
remain about the process undertaken to reach the final version of the UDBHR and how
that may affect the legitimacy of the declaration. Some have criticised the composition
of the drafting body as being too slanted towards human rights law and away from
bioethics perspectives, the transparency of the meetings and debates between the
drafters, and the willingness of the original drafters of the UDBHR to take into account
the concerns of the country delegates of UNESCO (Snead 2009). Other authors have
called into question the lack of public consultation with the broader bioethics commu-
nity (Macpherson 2007; Langlois 2011). We set aside this pertinent historical debate
and in the next section we provide a close textual analysis of the UDBHR to see if and
how these practically and politically important issues are addressed by the language
used in the document.

The Politics of Universality and

Legitimacy Regarding the
‘Universal Declaration on
Bioethics and Human Rights’

Two of the key political issues raised by the development of the UDBHR are the univer-
sality and legitimacy of this document and the process through which it was developed.
The first of the eight aims of the UDBHR is ‘to provide a universal framework of prin-
ciples and procedures to guide States in the formulation of their legislation, policies or
other instruments in the field of bioethics’. Thus, from the outset the writers and signa-
tories of the UDBHR adopt a universalist position regarding the ethical principles and
procedures that should guide the entirety of bioethics. In bioethics, principles are often
considered mid-level norms or rules, so that presumably all persons can hold them uni-
versally precisely because they do not appeal to any particular moral theory but are still
690   Diego S. Silva and Jeremy Snyder

action guiding. Stated differently, regardless of whether one is a classical utilitarian, is a

Kantian, or abides by rules of Confucianism, all can agree that principles, such as auton-
omy and beneficence, are important and ought to be promoted in the context of biology
and health. Debate may still remain about how to balance these principles in specific
contexts. Likewise, an appeal to procedures is an appeal to rules about how one ought to
go about doing bioethics. For example, if we (i.e., a group of reasonable persons) cannot
agree about what moral ends ought to guide the allocation of scarce resources, then we
should at least agree on the rules for fair allocation, so that regardless of the ultimate
outcome of allocative decisions (e.g., regardless of whether a particular resource is dis-
tributed on the basis of greatest need or greatest utility), everyone can agree that the
decision was made in a fair manner. Thus, by appealing to principles and procedures,
the universality espoused at the outset of the UDBHR implicitly accepts and potentially
endorses pluralism. In other words, the writers and signatories of the UDBHR seem to
acknowledge that there can be reasonable disagreement about what moral theories are
sound. In response, it places the idea of universality, not at the level of moral theory or
some overall set of moral beliefs, but rather at a level where its adherents presume every-
one can agree—namely, at the level of principles and procedures.
What the writers and signatories of UDBHR accept as the implicit truism of pluralism
in their articulation of the aims of the document, they make explicit in the preamble,
specifically in Article 12. In the preamble we see that members of UNESCO believe that
it is permitted to write the UDBHR, ‘[c]onsidering UNESCO’s role in identifying uni-
versal principles based on shared ethical values to guide scientific and technological
development and social transformation’. We might draw three conclusions from this
passage. First, members of UNESCO believe that there are such things as universal prin-
ciples, which is in keeping with the aim of the UDBHR described in the preceding para-
graph, as well as some form of pluralism. Second, members of UNESCO hold that these
universal principles are grounded in ‘shared ethical values’. It is unclear, however, exactly
what is meant by this phrase as used here. Do the writers and signatories believe there
are moral beliefs more fundamental than the principles that ground those of the
UDBHR? If so, are these more fundamental ethical values (whatever they are) shared by
those who hold different ethical theories? Third, from this brief passage we can begin to
deduce UNESCO’s claim and defense of the very legitimacy of the UDBHR itself,
namely, that UNESCO sees as part of its role the very identification of universal moral
principles in the context of science and human health. Thus, if part of the mandate of
UNESCO is to identify and write about universal moral values, then it has a prima facie
claim that it can legitimately write a bioethics declaration that the whole world ought to
follow. Those working at UNESCO, and with UNESCO, therefore believe that it can
legitimately create a document about the universality of moral principles and procedure
in bioethics. Whether or not UNESCO actually holds such a mandate, and if not,
whether it ought to have such a mandate, are key political questions raised by this claim.
In the preamble we also see UNESCO’s first description of what cultural diversity
is and its role in the UDBHR and bioethics more broadly. The writers of the UDBHR
state: ‘[b]earing in mind that cultural diversity, as a source of exchange, innovation
 Politics of Global Bioethical Frameworks   691

and creativity, is necessary to humankind and, in this sense, is the common heritage of
humanity, but emphasising that it may not be invoked at the expense of human rights
and fundamental freedoms’. First, cultural diversity is understood as the means of
exchanging ideas, presumably, and as a source of creativity. It is represented as ‘the com-
mon heritage of humanity’, perhaps suggesting that the diversity of thoughts that exists
between people and cultures is part of what it means to be human. Regardless of the
accuracy of the interpretation of this passage, the writers and signatories of the UDBHR
appear to hold cultural diversity as, on the whole, a good thing that ought to be promoted.
And yet cultural diversity comes second to human rights and fundamental freedoms.
Here we come up against a potential tension in the UDBHR, namely the exact nature of
the interplay between ethics and human rights (Andorno 2009). This passage states that
cultural diversity ought not to supersede fundamental human rights, such as security of
the person and equality regardless of race or gender. It would seem that the respect
afforded cultural diversity can itself be grounded in fundamental human rights, at least
as articulated in Articles 18 and 19 of the ‘Universal Declaration of Human Rights’ (UN
General Assembly 1948). This leads to controversial political questions about how the
various fundamental rights ought to be interpreted in light of each other, a topic dis-
cussed at length in the existing literature (Donnelly 2013). Under a charitable reading of
the UDBHR, one might rearticulate this passage using ethics language and conclude
that appeals to cultural diversity cannot be used to unjustifiably harm persons and their
basic interests or well-being.
Article 12 of the UDBHR reiterates the ideas of the passage from the preamble pre-
sented in the preceding paragraph, but adds the idea of pluralism. Article 12 reads: ‘The
importance of cultural diversity and pluralism should be given due regard. However,
such considerations are not to be invoked to infringe upon human dignity, human rights
and fundamental freedoms, nor upon the principles set out in this Declaration, nor to
limit their scope’. At first it would seem that the basic sentiment of this article is a reiter-
ation of the section found in the preamble. There is the invocation of cultural diversity
and how it is important and should be respected, but that it cannot be used to infringe
upon basic human rights (which again can be charitably reread to include ideas com-
monly found in ethics). Certain additions are made to this reiteration, namely that
cultural diversity cannot be used to infringe upon the principles set out in the
UDBHR. This would seem to follow from the logic of the document, that if the prin-
ciples of the UDBHR are based on (to some degree) and are meant to cohere with
basic human rights as articulated in other declarations and covenants of the United
Nations, and that cultural diversity cannot be used to infringe human rights and fun-
damental freedoms, then cultural diversity cannot be used to justify infringements of
the principles of the UDBHR. However, Article 12 not only deals with cultural diversity
but also explicitly introduces pluralism for the first time in the document. Pluralism
might thus be interpreted as being set apart, and held as distinct, from the idea of cul-
tural diversity. Two questions quickly arise: What did the writers and signatories of
the UDBHR mean by pluralism? And what are the differences between pluralism and
cultural diversity?
692   Diego S. Silva and Jeremy Snyder

It is not clear to us how the writers of the UDBHR would answer these two questions.
One possible response is to define pluralism in a manner that is commonly used in
moral and political philosophy, as outlined in the previous section—namely, that rea-
sonable people will reasonably disagree about metaphysical and epistemological beliefs,
and (most important for our purposes) ethical values and norms. Pluralism could then
be contrasted with an understanding of cultural diversity as cultural relativism, which
is the idea that norms, including ethical values and norms, are created and can only be
understood in the context of a person’s or group’s culture and, since there are many
different sets of cultures, the multitude of ethical values and norms that may or may
not cohere.
Crucially, significant political problems are created for the adoption and legitimacy
of the UDBHR if Article 12, and subsequently the entirety of the UDBHR, if it can be
interpreted as recognising not only pluralism but also cultural diversity as cultural rela-
tivism. That is because the embrace of pluralism and cultural relativism makes it unclear
how the writers and signatories to the UDBHR can make sense of the universality of
principles and procedures. At its most basic, universalism (the idea that norms can be
universalised) lies in contradiction to any form of relativism (the idea that norms
cannot be universalised), including cultural relativism. One might object to the validity
of this concern by arguing that the use of cultural diversity (as relativism) alluded to in
the UDBHR rests at the level of moral theory, but that maintaining cultural relativism is
consistent with upholding the universality of mid-level principles and procedures; as
such, there is no contradiction because each idea, cultural diversity or universalism,
refers to a different thing altogether. However, as discussed previously, the UDBHR
refers to the ‘shared ethical values’ upon which the universal principles of the document
are founded. True, it is unclear what exactly the writers of the UDBHR mean by the
phrase ‘shared ethical values’, but if it were to mean that the universal principles are
based on some other, more foundational values or norms that are themselves universal,
then it behoves the writers of the UDBHR to clarify what exactly is referred to by the
invocation of ‘shared ethical values’ and how this does not collapse into a contradiction
between cultural relativism and universalism. Moreover, allowing for the possibility of
coexistence between cultural relativism and universalism requires us to carefully
explain why we ought to believe that relativism only exists at the level of moral theory
and not principles. It is unclear what the details of such an explanation would be. It
seems we could argue that cultural differences only exist at some foundational levels
with regard to theory-driven values and norms but that universality is otherwise possible,
but then this would seem to at best collapse into pluralism (again, the idea that reason-
able disagreement exists about moral values and norms without rejecting universalism).
Moreover, if cultural relativism is sound, then the universality of mid-level principles is
contingent upon not finding any cultures that disagree with the principles themselves,
which is at best a weak conclusion.
Promoters of the UDBHR may also note that it is fundamentally a political document;
it is not intended to be a philosophical treatise and therefore should not be held to
 Politics of Global Bioethical Frameworks   693

the same rigour as traditional philosophical arguments. Cultural diversity just means
pluralism, or is a subset of pluralism (Revel 2009), and there is an unfortunate redun-
dancy in how Article 12 was written. In other words, the very nature of such documents,
with so many authors and signatories and governments to please, makes it impossible
(or highly improbable) to reach any kind of precision in language and argumentation
that makes it worth reading with too much attention to detail. Benatar (2005), for
example, has criticised the UDBHR precisely for being too minimalist and vague; the
ideas therein are intentionally written so that it actually says very little; all member states
can reconcile it with their values and perhaps adopt the declaration. But perhaps having
such a declaration, despite its limitations due to being minimalist and vague, is still
worthwhile. As ten Have (2016, 7) notes, ‘the request to develop normative instruments
frequently originates from developing countries. Since they have no, or weak, infra-
structures in the field of bioethics, they often are concerned that they may not be able to
participate in scientific and technological developments or that they will be confronted
with the negative fall-outs’. As such, instruments such as the UDBHR serve the interests
of those most vulnerable states (i.e., low-income countries) and those people who are
most vulnerable within those states. Whether or not such instruments provide any real
benefit to low-income countries is an empirical question that falls beyond the scope of
this chapter. Still, the original objection remains: the purpose of the UDBHR is not to
appease the philosophers of bioethics but rather to exist as a political instrument that
protects all people and promotes ethical development of science for the sake of improve-
ments in health; as such, any logical inconsistencies, if sufficiently minor (such as using
cultural diversity to refer only to pluralism), should be ignored.
Moreover, political arguments in support of UNESCO’s legitimacy in writing a dec-
laration on bioethics in the first place lean on the idea that maintaining some consistency
between the idea of cultural diversity (understood charitably) and the universality of
principles and procedures is necessary. In writing about her involvement in the process
of drafting and conducting consultations on the UDBHR as chair of the International
Bioethics Committee at UNESCO, Stanton-Jean (2016, 14) notes: ‘I thought that it was a
great moment for Bioethics. For the first time a global political statement in the field of
Bioethics was adopted by all member states of UNESCO’. The fact that all member states
accepted the document would seem to bode well for the document’s legitimacy.
However, the adoption itself is based on balancing cultural diversity with universalism.
Citing former director general of UNESCO Kōichirō Matsuura, Stanton-Jean (2016)
points out that the reason the UDBHR is a declaration and not a covenant (where the
former is generally understood as providing very important recommendations that take
the force of soft law, as opposed to the latter, which are binding agreements between
signatories) is the recognition on the part of the writers and signatories that global bio-
ethics is complex and must take into account a wide variety of cultural contexts. Moreover,
she notes (again citing Matsuura) that the principles are written in a broad manner, so
that all member states can accept and see themselves in the UDBHR, given the global
nature of health research and delivery. Thus, the nature of the UDBHR as a declaration
694   Diego S. Silva and Jeremy Snyder

might be interpreted as speaking to the idea of a cultural diversity, whilst articulating

broad (perhaps ‘vague’ to use the language of Benatar) principles that are used to retain a
sense of universality.
The politics of the drafting of the UDBHR, however, do problematize this conclusion.
Even if it is true that all member states accept the UDBHR, this does not tell us that the
declaration was written in a manner that is genuinely inclusive of all cultural viewpoints
and does not ensure that some member states, perhaps those with less global power,
did not feel pressured to accept its principles and procedures (Macpherson 2007)
(assuming, for the sake of argument, that inclusiveness and making decisions in the
absence of pressure confer an ethically acceptable form of agreement). This may very
well be the case. Again, however, much like the question about how successful the
UDBHR is in practise, this is an empirical question within the purview of historians,
anthropologists, and sociologists. Research on this question, as far as we know, has not
been extensively conducted, but we would certainly welcome it. For now, unless evi-
dence to the contrary is presented, the benefit of the doubt should go to the writers and
signatories of the UDBHR.
The legitimacy of the UDBHR may also rest, in part, on whether one accepts the very
mandate of UNESCO itself. ten Have (2016, 6) notes that ever since Julian Huxley, the
first director general of UNESCO, the organisation’s ‘mission and its mandated work
in the areas of education, culture, science and communication, the organisation from
the start emphasised its role as “moral conscience” ’. Since its beginnings, therefore,
UNESCO has seen the articulation of values that are acceptable to all member states as
part of its mandate. This would be in keeping with the language of the preamble, dis-
cussed previously, namely that UNESCO has a ‘role in identifying universal principles
based on shared ethical values’ (UNDBHR). ten Have also notes that ‘UNESCO is a
global platform for bioethics that brings together moral perspectives from all countries
on an equal basis (at least in principle since in practise some member states will be more
involved than others). This is easier said than done’ (ten Have 2016, 7). He states that ‘the
major challenge [for the International Bioethics Committee] is always to reconcile an
aspiring universal discourse with respecting local diversity’ (ten Have 2016, 7). Thus
there exists recognition of the tension between cultural diversity (as pluralism) and
universalism, which needs to be balanced, and that eschews any simple answers or solu-
tions. Again, how well this is done in practise requires further investigation, but it is at
least heartening that the tension is acknowledged by the International Bioethics
Committee and UNESCO, rather than merely ignored.
In summary, a charitable reading of the UNDBHR suggests that the writers and sig-
natories wanted to promote a culturally relevant and diverse interpretation of universal
bioethical principles and procedures, whereby the idea is to be sensitive to the differences
between cultures and countries with regard to the very nature of ethics and bioethics,
without collapsing into any sort of relativism. The legitimacy of the UNDBHR rests in
part on acceptance of (a) such universality existing and (b) UNESCO being the appro-
priate place to discuss universal ethics values, norms, and principles, which it seems
UNESCO believes it has the authority to do.
 Politics of Global Bioethical Frameworks   695

Moving Forward on Universal

Bioethical Principles

Whilst remaining neutral about the desirability of UNESCO, or any other international
group, developing and promoting universal bioethical principles, in the remainder of
this chapter we wish to suggest some steps that would increase the cogency and legitim-
acy of any such endeavour. First, any such document must be philosophically rigorous, in
the sense that it should be clear and consistent in its use of terminology and concepts
drawn from philosophical ethics and political theory. As our discussion has shown, fun-
damental terms such as pluralism, universalism, and relativism have complex and often
contested meanings built on a long tradition of ethics scholarship. The failure to connect
the use of these terms to this history and to stipulate their meaning clearly in such a
document all but ensures that the response to any declaration of bioethical principles is
likely to focus on debates over its meaning and validity rather than on its promotion and
enforcement.
This is not to say that a declaration such as the UDBHR should devote extensive space
to engaging in meta-ethical debates over the meaning of core ethics concepts; rather,
clarity is needed about the understanding of these concepts for the purpose of any dec-
laration, either in the declaration itself or in a companion document. This is true not
only for overarching concepts such as universality, but also for those key concepts that
make up the substance of the declaration. For example, Article 10 of the declaration
maintains that humans should be understood as having fundamental equality with one
another in terms of their dignity and rights ‘so that they are treated justly and equitably’.
As stated, it is unclear how justice and equity are meant to be understood for the pur-
pose of the declaration and how they relate to one another. Are these two ways of saying
the same thing or distinct concepts with important differences? If the former, are they to
be understood as shorthand for equality of dignity and rights or to be understood differ-
ently? If the latter, how are these two concepts differentiated, and are they compatible
with one another and with equality of dignity and rights? These are fundamental ques-
tions, drawn from a long history of debate in ethics and political theory. Without linking
these concepts to a specific interpretation of their meaning, any declaration is likely to
mean everything to everyone whilst failing to offer guidance in important areas of con-
tention in global bioethics.
As a second step, UNESCO and other bodies can promote the development, legitim-
isation, and use of universal bioethical principles by supporting smaller declarations
and documents that span regions or cultural or ethnic groups. This approach might
seem counterintuitive, as declarations by regional or cultural groups have the potential
to be at odds with one another, thus supporting a view of bioethics as relativistic rather
than universal. However, there are important advantages to this approach for defenders
of universalism in bioethics. A significant benefit of these regionally and culturally specific
declarations is that they would allow for the specification of universal values. That is,
696   Diego S. Silva and Jeremy Snyder

they would allow these groups to take a fairly vague principle such as the UDBHR’s
Article 13 (‘Solidarity amongst human beings and international cooperation towards
that end are to be encouraged’) and address this vagueness by adding substance to the
meaning of ‘solidarity’ and practical suggestions about how to promote this value.
This proc­ess of specification to local context supports rather than threatens the goal of
universalism by demonstrating how the general but necessarily vague principles
­outlined in the UDBHR can be applied to specific contexts. As such, specification rec-
ognises pluralism in local contexts without accepting claims of relativism regarding
morality and political theory.
As a part of this process of specification, these targeted bioethics declarations should
explicitly link themselves to the cultural and religious traditions of such groups. There
are several advantages to doing so. First, as Nie Jing-Bao (2005) points out, linking the
principles of the UDBHR specifically to non-Western cultures helps to defuse the con-
cern that the principles stated in the UDBHR reflect typically Western ethical norms.
A demonstration that these principles can be specified to, and supported in, non-
Western contexts is extremely important to the legitimacy and claims of universality of
this declaration. Showing the plurality of specifications of the UDBHR principles helps
to counter proponents of cultural relativism and, as Nie argues, additional supporting
arguments for universalism can be found in non-Western traditions such as Confucianism
and Daosim (Nie 2005, 255–256). Furthermore, we can view this process of local specifi-
cation as bidirectional, with the UDBHR providing content that is locally specified but
ideally remaining open to refinement and revision, given continued reflection and oper-
ation in the pluralistic cultures and regions in which it applies. For example, local speci-
fications of autonomy that include a core value of community consultation and
inclusiveness might serve to inform and provide more detail on the appearance of that
value in the UDBHR.
Finally, these smaller declarations of bioethical principles can help to build both con-
sensus and legitimacy around universal bioethics values and norms as articulated in
universal bioethics declarations. By establishing that the general principles of the
UDBHR can be specified to local cultures and contexts successfully, these applications
would help demonstrate the universalizability of these principles, whilst embracing
pluralism. Moreover, the development of local specifications of the UDBHR would
likely have an important practical effect of contributing to political support for and
practical implementation of this declaration. These targeted declarations would have
the appeal of encouraging action by specific states and communities to demonstrate the
relevance of the UDBHR to their context and defuse concerns that it is a neocolonial
or Western imposition on their cultures by a distant UN bureaucracy. Since the creation
of these targeted documents would necessarily include participation by a wider range of
local political leaders, policymakers, health experts, bioethicists, cultural leaders, com-
munity members, and patient advocates, the process of developing these specifications
would have the added benefit of further strengthening the legitimacy of both the targeted
documents and UDBHR by demonstrating the inclusivity of the latter’s development
and continued refinement. Where these targeted documents could be given the strength
 Politics of Global Bioethical Frameworks   697

of law and linked explicitly to the UDBHR, they have an important ability to make it
much more practical without requiring that it be granted the power to enforce its prin-
ciples on signatory states.

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 Index

Note: Figures, tables and boxes are indicated by an italic “f ”, “t” and “b” and notes are indicated
by “n” following the page numbers.

A agency forms of power 61, 65, 71–73

abortion 28–29, 53 agenda setting 325–38
access to medications 605–22 actors involved in 326–28
actors involved in 615–17 ascendance of issues in 334, 633–34
antiretrovirals 108, 271, 303, 330–33, BRICS countries in 306, 317, 318
613–16 exclusionary practices in 69
antivirals 6, 89, 91, 541 future research needs 336–38
barriers to 111, 396 gender issues and 249–51, 253–54
global health initiatives for 607–8 in global health diplomacy 113
global politics of 605–6, 612–22 health security and 173
history of concerns regarding 608–10 ideas in 328–30
human rights and 4, 42, 544 institutional influences on 332–33
importance of 606–7 interests in 330–32
innovation and 610–12, 618–19 models for 335, 337–38
intellectual property protection and 47–48, at national and subnational levels 335
287–88, 396 for NCDs 328, 632
for NCDs 646 overview 325–26
vaccinations 42, 188, 397, 536, 544–45, 607 WHO as venue for 303
Ackland, M. 647 Aginam, Obijiofor 389, 569
Adger, W. Neil 153 aging populations. See elderly populations
administrative capacity of states 147 Agreement on the Application of Sanitary
adolescents. See children and adolescents and Phytosanitary Measures
Adorno, Theodor 91 (SPS Agreement) 428, 434
Advocacy Coalition Framework Agreement on Trade-Related Aspects of
(ACF) 335, 338 Intellectual Property Rights (TRIPS)
Afghanistan, tailgate medicine in 208–10 advocacy groups on 356, 396, 610
Africa affordability of medications and 434
decolonization in 553 BRICS countries’ negotiations on 111, 304,
development assistance for 108, 308, 309, 306, 307
313, 319n1 commodification of innovation
Ebola in. See Ebola virus disease through 452–53
health inequality in 59 cross-retaliation principle in 455
influenza pandemics in 532 disadvantages for low-income countries
pharmaceutical sector in 311, 312 72, 360, 504
third world movements in 25 Doha Declaration and 333, 360, 475
tobacco markets in 663 on generic medications 48, 271, 333, 353,
vaccination campaigns in 587 360, 475, 559
700   index

AIDS. See HIV/AIDS antiretroviral therapies (ARTs)

AIIB (Asian Infrastructure Investment access to 108, 271, 303, 330–33, 613–16
Bank) 10, 304–5 anticolonial views of 97
alcohol use in BRICS countries 111, 307, 311
collective action for regulation of 391–92 collective responsibility of international
cost of interventions for reduction community for 500
of 632 as preventive therapy 562
deaths resulting from 391 prices for xiii, 475, 559, 613–15
gender differences in 241–43 production centers for 311
in global health policy agenda 328 (RED) project for 413–14, 417
Global Strategy to Reduce the Harmful use right to health and 502
of Alcohol 112b, 391 antiviral medications
as NCD risk factor 629–31 access to 6, 89, 91, 541
promotion of responsible drinking 395 conflicts of interest in recommendation
Alexander the Great 198 of 357
Allen, Luke N. 634, 647 recognition of utility of 534
Alma-Ata Declaration (1978) stockpiling of 130, 536, 539
as application of basic needs approach to apartheid 369, 553, 569–70
health 449 Appau, Adriana 399
economic affordability and 249 Aristotle 245
on human right to health 505 Armbrister, Adria 70
ideational legacy of 48 ARTs. See antiretroviral therapies
on new international economic Asia
order 505–6, 591 bubonic plague in 21
on primary healthcare 30, 44–47, 51, influenza pandemics in 533, 534
224–25, 315, 329, 371 SARS in. See severe acute respiratory
Amorim, Celso Nunes 669 syndrome
AMR. See antimicrobial resistance state-led global integration in 47
Amsden, Alice 596 third world movements in 25
Annan, Kofi 145–46, 326, 560, 670 tobacco markets in 663
anthrax 6, 129, 130, 164, 182, 614 vaccination campaigns in 587
anthropology Asian flu pandemic (1957) 533, 541
analytical contributions of 479–80 Asian Infrastructure Investment Bank
conceptualizations of power in 62–64, 73 (AIIB) 10, 304–5
critical thinking in 89 Assunta, Mary 669, 672
in global health politics 7 Attaei, Marjan, 646
medical 62, 63, 73, 353 authority, sources of 275, 349
militant 480 Avant, Deborah D. 275
research methodology in 63–64, 75 avian influenza (H5N1/H7N9) 128, 155,
antiglobalism 39, 53, 379 184–85, 188, 535–37
antimicrobial resistance (AMR) Aylward, Bruce 207
from antibiotic overuse 131, 268
defined 130 B
governance of 273–74 Bacillus Calmette-Guérin (BCG)
pharmaceutical intervention and 5 vaccine 585–88
R&D for 619, 621 Baker, Michael G. 516
as security threat 130–32, 134 Ban Ki-Moon 226, 228, 327
 index   701

Bankoff, Gregory 126 biosecurity 179–92

Barnard, David 504 as biodefense 180–83, 191–92
Barnett, Jon 153 as border security 189–92
Barnett, Michael 349–50 censorship and 185, 192
Barnett, Tony 558 defined 179–80
Barnett-Duvall typology 74–75 global health risks from 183, 185–86,
Bashford, Alison 125 191–92
BAT. See British American Tobacco as health security 186–89
Baumgartner, Frank R. 338 as information security 183–86, 192
BCG (Bacillus Calmette-Guérin) security dilemmas in 181, 183
vaccine 585–88 bioterrorism
Béhague, Dominique P. 329 agenda setting for 331
Beltrán-Sánchez, Hiram 242 anthrax letters as 6, 129, 130, 164, 614
Benatar, Solomon R. 268, 271, 400, 445, 693 fears regarding 6, 110
Bendavid, Eran 114 preparedness planning for 132, 133
Bergh, Kristofer 113 as security threat 103, 129–30, 132
Bero, Lisa 398 bird flu. See avian influenza
Berry, Christine 400 Birn, Anne-Emmanuelle 507
Bettcher, Douglas 667 birth control 27–28, 397–98
Bhattacharya, Jayanta 114 Black, Robert E. 421
Bhopal industrial disaster (1984) 169 Blair, Tony 5, 47, 267
biases. See discrimination; stigma Blindspot (Keshavjee) 222
Bill and Melinda Gates Foundation (BMGF) Bloomberg, Michael 4, 647, 674
Anti-Tobacco Trade Litigation Fund 437 Bloomberg Philanthropies 437, 674, 677
on cause-related marketing 375 Blume, Stuart 583
criticisms of 417–21 BMGF. See Bill and Melinda Gates
emergence of 112, 218, 270, 373, 409 Foundation
functions of 325 Bonita, Ruth 640
funding for 225, 274, 412 Bono 273, 414
GAVI Alliance sponsorship by 594 Booth, Ken 164
global health agenda of 53, 411–16 border-based biosecurity 189–92
home base for 50 Bourdieu, Pierre 72
on influenza pandemic Bracht, Caroline 305
preparedness 538–39 brain drain 38, 46, 52
tobacco control funding from 674 Brazil. See also BRICS countries
in transnational state 290 bubonic plague in 21
BINGOs (business-interest NGOs) 368, 377 civil-military relations in 202
biodefense 180–83, 191–92 conditional cash transfer programs in
bioethics. See Universal Declaration on 285, 315
Bioethics and Human Rights development assistance from 303, 308,
biological weapons. See also bioterrorism 310, 311
anthrax 6, 129, 130, 164, 182, 614 on FCTC 669, 673
process for wielding 181 global health diplomacy by 108, 111, 306
proliferation of 110, 180 pharmaceutical sector in 311, 614
Soviet program for 130 Zika virus in 166, 201–3
state-centric approach to 315 breastfeeding 30, 31, 49, 450
biopower 95–96 breast-milk substitutes 31, 356, 392
702   index

Brexit 10, 441, 563 business sector 387–403. See also

Bricknell, Martin C. M. 209 public-private partnerships
BRICS countries 301–19. See also Brazil; collective action to regulate
China; India; Russia; South Africa health-harming industries 390–93
competing visions of 312 contributions to public interest 393–98
development assistance from 303, defined 388–89
308–13, 318 in global health governance 398–400
domestic health models of 307, 315–17 overview 387–88
emergence of 42, 301 role in global health politics 401–3
engagement with global health types of organizations in 388b
­governance 302–7, 311, 317–19 Butler, Judith 168
global health diplomacy by 303, 306, 318 Buzan, Barry 145, 146, 149
health challenges in 301–2, 309
institutional influence of 302, 305–8 C
material capabilities of 308–11 Cabrera, Oscar 643
NCDs in 630 Callahan, Daniel 571
pharmaceutical sector in 311–12, 318, 597 Calmette, Albert 585
state-centric approaches by 313–15, 319 Cameron, Edwin 559
venues for engagement by 303–5 cancer medications 618
British American Tobacco (BAT) 394, 395, Candau, Marcolino Gomes 25, 26, 589
434, 663, 667–73, 676–77 capabilities approach 70, 145, 154
Brown, E. Richard 418 capacity-based authority 275
Brundtland, Gro Harlem capitalism
background of 34 alternatives to 447
on disease and globalization 268 cause-related marketing and 375
on enlightened self-interest 579 climate change and 229
on investments in health 51 critiques of 67, 87, 90–92
on partnerships 396, 518 environmental degradation due to 222–23
promotion of global health issues 93, 272 exploitation under 24, 219
on provision of services 562 globalization and 38, 45, 49, 52
tobacco control initiatives of 666, 670 Great Transformation to 217, 219–20
travel restrictions issued by 351 late stage 390
Bryant, Toba 65 neo-liberal 266, 271
bubonic plague philanthrocapitalism 94, 377, 416
biodefense activities involving 182 population growth and 27, 28
International Health Regulations on 25 power differentials in 65
quarantines for 126, 135 private interest groups and 368
as re-emerging disease 32 regulatory 642
societal instability and 152 Capitalocene 222
transmission of 21 Caribbean Community (CARICOM) xiii, 634
Buffett, Warren 225, 274, 412 Carnegie, Andrew 410
Bump, Jesse B. 329 Cash, Richard 136
bureaucratic culture theory 349–50 Casswell, Sally 391
Busby, Josh 331 Castells, Manuel 379
Buse, Kent 237, 302, 310 cause-related marketing 375
Bush, George W. 108, 270, 560 CCT (conditional cash transfer)
business-interest NGOs (BINGOs) 368, 377 ­programs 285, 315
 index   703

CEA (cost-effectiveness analysis) 115, 451 mortality rates for 59, 109, 152, 221, 227
celebrity diplomacy 414 in poverty 153
censorship 185, 192 Task Force for Child Survival 592, 595
Centers for Disease Control and Children’s Vaccine Initiative (CVI) 593–94
Prevention (CDC) China. See also BRICS countries
bioterror preparedness by 130 Belt and Road initiative in 305
disease eradication efforts 594, 596 development assistance from 108, 308–11,
on Ebola outbreak 265, 352 313, 319n1
on HIV/AIDS emergence 553 economic and political rise of 10, 227,
influenza sample testing by 538 434–35
tobacco control efforts 631, 674 on FCTC 669
CEPI (Coalition for Epidemic Preparedness influenza pandemics in 533, 534
Innovations) 539 life expectancy in 316
CETA. See Comprehensive Economic and military assistance from 204
Trade Agreement pharmaceutical sector in 312
Chagas, Luiz Carlos 306 population control in 28
Chan, Jennifer 272 primary healthcare in 30, 44, 316, 449
Chan, Margaret R&D investment by 621
on access to medications 605 SARS outbreak in 128, 136, 307, 351, 516, 518
on alcohol industry 392 state-centric approach in 314–15
avian influenza outbreak response by 535 Chisholm, Brock 24
on BRICS countries 301 cholera
critique of globalization by 48 failure to detect outbreaks 517
cross-border outbreaks under 519 International Health Regulations on 25
Ebola outbreak response by 190, 273 quarantines for 20, 21, 126
on global health actors 270 as re-emerging disease 32, 88
on outbreak reporting 522, 523 societal instability and 151–52
on universal health coverage 315 spread by UN peacekeepers 356, 357
Chan, Priscilla 413 transmission of 20, 21
Chandhoke, Neera 372 Chorev, Nitsan 51, 350
Chang, Ha-Joon 220 Chowdhury, A. 284
Chan Zuckerberg Initiative 413 cigarettes. See tobacco use
Chapman, Audrey R. 502 CIOMS (Council for International
Chapman, Simon 669, 672 Organizations of Medical
Chen, Ingfei 412 Sciences) 688–89
Chernomas, Robert 64–65 Cipla 613–14
CHGA (Commission on HIV/AIDS and civil liberties 134–35, 138, 146, 163, 167, 379
Governance in Africa) 560 civil-military cooperation 199–201, 205–8
chikungunya 166 civil rights 494–95, 497–501
children and adolescents. See also United civil society organizations (CSOs) 367–80
Nations Children’s Fund on access to medications 333, 616
in conflict areas 153, 157 as actors in global health politics 4, 6, 427
Convention on the Rights of the in agenda setting 328, 332
Child 494, 644 categorization of 372–73, 377
GOBI interventions for 30–31, 49 change efforts of 356
marketing of food and beverages conceptualization of 367–69
to 115, 633 corporate capture of 375–76
704   index

civil society organizations (CSOs) (Continued ) communicable diseases

digital technology and 379 agenda setting for 331
diversity of 368, 372, 377 early detection and surveillance 4, 513
exclusion of participation by 315 globalization and 268, 270
in global health governance 373–74, 378 in refugee camps 151
HIV/AIDS activism by 565 regulations to prevent spread of 267
human rights as leverage for 508 soft power tools for control of 114
mobilization against trade agreements 436, communism 25, 28, 91
439, 441 Communist Manifesto (Marx) 229
overview 367 companies, defined 388b
political nature of 368–69, 637 Comprehensive Economic and Trade
primary healthcare promotion by 371–72 Agreement (CETA) 107, 399, 435,
as tobacco control advocates 670 439, 440
transnational 290, 356, 372 compulsory licensing 504, 559, 613–15, 617
climate change compulsory power 74
capitalism and 229 conditional cash transfer (CCT)
in emerging and re-emerging diseases 33 ­programs 285, 315
global health impacts of 223 confidentiality 32, 357, 514, 523
globalization and 6, 222–23 conflictual power 72
Intergovernmental Panel on 223 Connell, Raewyn 251, 252
mitigation strategies 379 consent, informed 198
NCD-informed policies and 645 constructivism 113, 349, 493–94, 500
organizational change in response to 354 consumer-driven philanthropy 413–14
skepticism regarding 97 contraception 27–28, 397–98
Sustainable Development Goals on 228 Convention on the Rights of the
Clinton, Bill 47, 557 Child 494, 644
Coalition for Epidemic Preparedness Cooper, Andrew F. 414
Innovations (CEPI) 539 copyrights 353
Coburn, David 65 Cornwall, Andrea 250
Coca-Cola Company 397, 402 corporate social responsibility
Cold War 24–25, 87, 106, 497, 554, 588 (CSR) 395–98
collective violence 151 corporations, defined 388b. See also
Collins, Pamela Y. 70 ­transnational corporations
Collishaw, Neil 664 corruption 9–10
colonialism Cortell, Andrew P. 351
economic development and 220 cosmopolitanism 113–14
Enlightenment and 86–87 Costa e Silva, Vera Luiza da 669, 673
health policies during 20, 43, 49 Costa-Font, Joan 402
tropical medicine and 20, 44, 125–26, cost-effectiveness analysis (CEA) 115, 451
171, 199 Costello, Andrew 223
Commission on HIV/AIDS and Governance Council for International Organizations of
in Africa (CHGA) 560 Medical Sciences (CIOMS) 688–89
Commission on Human Security 147, Courtenay, Will H. 242, 244
149–56, 158n1 Coutinho, Alex 553–54
Commission on the Status of Women Cox, Robert 8, 302
(CSW) 238, 247 Crenshaw, Kimberlé 68, 240–41
common security. See human security critical race theory (CRT) 67–68, 90
 index   705

critical security studies (CSS) 161–73 medical assistance programs 87, 108
defined 163 primary healthcare in 44
emergence of 161, 162 Cueto, Marcos 19
global health politics and 170–73 cultural diversity, UDBHR on 690–94
on health security 164–70, 173 cultural relativism 687, 692, 696
overview 161–62 cultural rights. See International Covenant on
politics of security and 162–64 Economic, Social, and Cultural Rights
on risk-based mentality 165–66 culture for health 552
“security as emancipation” approach Cunningim, Merrimon 417
in 164, 168, 173 CVI (Children’s Vaccine Initiative) 593–94
theoretical approaches to 163
vulnerability in 168–70, 173 D
critical theory Dahl, Robert A. 61
critical race theory 67–68, 90 DALYs. See disability adjusted life years
criticisms of 96–97 Danzon, Patricia M. 415
defined 91 Davies, Sally C. 131, 552
of economics 90 Davies, Sara E. 513
Frankfurt School on 91, 97, 162 DDD (digital disease detection) 514, 517, 524
intersectionality in 68–70, 73 DDT (dichlorodiphenyltrichloroethane) 26,
on neo-liberal globalization 92 350, 361n2, 419
on philanthropic giving 94 Deaton, Angus 552
securitization theory 94–95, 134, 163–65 de Beauvoir, Simone 237
critical thinking 85–98 De Bengy Puyvallé, Antoine 374
as academic activity 96–97 debt crises 38, 45–46, 88, 288, 471
on biopower 95–96 DeLaet, Debra 187
in Enlightenment 86–87, 89, 90 delegated authority 275
epidemiological events and 89 dengue fever 32, 155, 166
in epistemic communities 89–90 de Quadros, Ciro 595
on neo-liberalism 92 Desai, Sapna 64
overview 85 descriptive approach to human rights 494,
on political economy 91–93 495, 503–7
on (RED) project 93–94 determinants of health
on representation 94–95, 165 commercial 677
social movements and 90, 97 gender 240–41, 250–53
stakes of 98 globalization effects on 6, 40
varieties of 90–91 political 62
Critique of Pure Reason (Kant) 86 social. See social determinants of health
cross-retaliation principle 455 upstream 111
CRT (critical race theory) 67–68, 90 development assistance
CSOs. See civil society organizations access to medications and 607
CSR (corporate social responsibility) 395–98 altruistic motivations for 287
CSS. See critical security studies from BRICS countries 303, 308–13, 318
CSW (Commission on the Status of from developing countries 225
Women) 238, 247 exertion of power through 74
Cuba in foreign policy 109
HIV/AIDS quarantines in 135 for HIV/AIDS 286–87
independence from Spain 21 impact on health expenditures 226, 283
706   index

development assistance (Continued ) Doll, Richard 661

for NCDs 287, 627 Dollar, David 221
NGO-isation 372 domestic resource mobilization (DRM) 507
official 92, 224, 288 Doughnut Economics (Raworth) 223
philanthropic 411–13 Dow Chemical 400
South-South partnerships 111, 313 Drèze, Jean 282
state-centric approach to 314–15 drugs. See medications
strategic use of 107–8 Drugs for Neglected Diseases Initiative
Devlin, Stephen 400 (DNDI) 572
dichlorodiphenyltrichloroethane (DDT) 26, Dry, Sarah 269
350, 361n2, 419 Duncan, Thomas Eric 123, 124, 137
digital disease detection (DDD) 514, 517, 524 dysentery 198
diphtheria 32, 584–85
diplomacy. See global health diplomacy E
disability adjusted life years (DALYs) 50–51, EBM (evidence-based medicine) 245, 329,
309, 454, 629, 630 541–43, 545
discrimination. See also stigma Ebola virus disease (EVD)
gender 70 agenda setting for 331, 334
intersectionality and 69 border-based biosecurity response
racism 63, 67 to 190–92
in trade barriers 430, 431 containment strategies 135, 155
diseases economic impact of 155
burden of. See global burden of disease medical personnel assistance with 108, 190
communicable. See communicable diseases military assistance with 201, 204–6
epidemics. See epidemics mortality rates 204
globalization and 125, 128, 171, 268, 270, outbreak reporting 514, 515, 517, 520
592–96 PHEIC declaration for 166, 190
infectious. See infectious diseases public fears regarding 123–24
insecurity and 125–27 as security threat 103, 124, 128, 165
lifestyle 154, 156, 664 societal instability from 152, 154, 157
NCDs. See non-communicable diseases structural adjustment programs and 472–73
poverty and 154 travel and trade restrictions for 136–37,
reporting. See outbreak reporting 190–91, 331
social and economic impact of 125, 128, 132 treatments for 312, 313
tropical. See neglected tropical diseases WHO response to outbreak 9, 265, 275, 359
vulnerability to 33, 39, 126, 128, 173 e-cigarettes 394–95, 642
zoonotic 127, 532, 551, 554, 572 economic globalization
dispositional power 72 consolidation of ownership in 388
dispute settlement mechanisms 399, 429–37, disease eradication and 592–96
440, 455, 477 material breakdown of markets in 48
DNDI (Drugs for Neglected Diseases neo-liberal ideology and 65
Initiative) 572 organizational change in response to 354
Doctors without Borders. See Médecins sans tobacco industry and 663
Frontières trickle down effect of 221
Dodds, Susan 169, 170 economic growth and development
Doha Declaration (2001) 333, 360, 475, in colonial era 220
614–15 core values of 450
 index   707

gender inequality and 152 Europe and European Union

global health and 3, 50, 218 beef import dispute 434
in Great Transformation 217, 219–20 Better Regulation initiative in 400
improvement projects for 87–88 Enlightenment in 86–87
international health and 19, 26, 34 Great Divergence with settler colonies 217,
lifestyle diseases and 156 219–20
market civilization model of 271 Great Transformation in 217, 219–20
neo-liberal views of 46–47 health inequality in 59
population control in 27 human development indicators for 230
state capacity and 147, 148 influenza pandemics in 532, 534
trade liberalization for 446 Marshall Plan for 224
economic inequality 284, 370, 390, 478 on medication pricing 620
economic rights. See International Covenant social movements in 368
on Economic, Social, and Cultural tobacco markets in 663
Rights tobacco use patterns in 241
ECOSOC (United Nations Economic and trade agreement ratification in 440
Social Council) 238, 247, 639 vaccination campaigns in 586–87, 598
Eide, Asbjorn 500 EVD. See Ebola virus disease
Eisenberg, Pablo 417 evidence-based medicine (EBM) 245, 329,
Elbe, Stefan 126, 131–33, 165 541–43, 545
elderly populations 153–54, 157, 329 Expanded Programme on Immunisation
electronic nicotine delivery systems (EPI) 590–92, 597, 599
(ENDS) 394–95, 642 expert authority 275
Emanuel, Ezekiel J. 562, 563 Exxon Mobil Malaria Initiative 395
emerging infectious diseases (EIDs)
characteristics of 32–33 F
global surveillance of 91, 133 Falk, Richard 570
lack of response to 88 family-planning programs 27–29, 356
threats posed by 127–28, 133, 535, 543 Family Smoking Prevention and Tobacco
zoonotic 127 Control Act of 2009 429–30, 432
Enemark, Christian 179 Fanon, Frantz 87
Engels, Friedrich 219 Farley, John 410
Enlightenment 86–87, 89–91, 95, 97 Farmer, Paul 47, 88, 480
EPI (Expanded Programme on Faude, Benjamin 359–60
Immunisation) 590–92, 597, 599 FCTC. See Framework Convention on
epidemics. See also pandemics Tobacco Control
blame of foreigners for 20 FDA (Food and Drug Administration) 27,
chronic 155, 156 415, 429–32
as drivers of innovation 89 Feachem, Richard 470
industrial 390–91, 477, 632 Feigl, Andrea B. 647
politics of response 91 Felski, Rita 96–97
societal instability during 151–52 females. See gender; women
sudden-onset 155–56 Fenner, Frank 594
epistemic power 72 FENSA (Framework for Engagement with
Essential Medicines List 608–10, 615 Non-State Actors) 375
ethical relativism 687 Fidler, David 7, 90–91, 106, 112, 133–34, 269,
ethnography 63–64, 70, 73, 353 287, 516, 521–22
708   index

Figuié, Muriel 114 French Declaration of the Rights of Man and

Finlay, Carlos 21 of the Citizen (1789) 495
Finnemore, Martha 275, 349–50 Frerichs, Ralph R. 357
firms, defined 388b Frerks, Georg 199
Fleming, Alexander 552 Freud, Sigmund 96
flu. See influenza Friedman, Milton 220, 221, 230
focusing events 113 Frist, Bill 130
Foege, William 592, 595 Fuchs, Doris 411
Food and Drug Administration (FDA) 27, Fukuda, Keiji 522
415, 429–32 Fukuda-Parr, Sakiko 147
food industry 392–95, 476–77, 629–30, Fund for Research in Neglected Tropical
637, 644 Diseases (FRiND) 573
foreign military assistance (FMA) 201, Furst, Thomas 571
204–6
foreign policy. See also international relations G
of donor nations 26 Gafton, Joseph 367
health in relation to 105–14 Gagnon, Michelle L. 112
hierarchy of functions of 106, 106f Gallagher, Allen 676
on population control 28 Galtung, Johan 268, 480
soft power in 111 Garrett, Laurie 6, 88
for-profit organizations. See business sector Gates, Bill and Melinda 4, 49–50, 225, 273,
Forsythe, David P. 499 412, 597. See also Bill and Melinda Gates
Foucault, Michel 95–96 Foundation
Fouchier, Ron 184–85, 520 GATS (General Agreement on Trade in
Foundation for a Smoke-free World 642, 676 Services) 428, 434, 452
Fowler, Norman 555 GATT (General Agreement on Tariffs and
Framework Convention on Tobacco Trade) 428–29, 433, 474, 610
Control (FCTC) GAVI. See Global Alliance for Vaccines and
alliance-building in support of 668–71 Immunizations
evidence base for 667–68 gay populations. See homosexuality
in global health diplomacy 672 GBD. See global burden of disease
in human rights framework 643–44 GBH (greedy bastards hypothesis) 67
on illicit tobacco trade 675–76 GCM/NCD (Global Coordinating
implementation of 673–74, 677 Mechanism for Noncommunicable
as international agreement 103, 112b Diseases) 639, 640
leveraging of interests in 332 gender 237–54. See also gender inequality
mobilizing political support for 665–67 conceptual framework for health
negotiations on 111, 306, 328, 332 and 240–46, 240f
nonbinding nature of 633 defined 238
opposition to 307, 376, 668–74 as determinant of health 240–41, 250–53
on protection of public health 391, 631 discrimination based on 70
on tobacco industry interference in health global burden of disease and 239, 253
policy 394 in global health agenda 249–51, 253–54
Framework for Engagement with Non-State health behaviors and 241–44
Actors (FENSA) 375 HIV/AIDS and 562
Frankfurt School 91, 97, 162 in international development 250
Freire, Paulo 552, 565n2 life expectancy and 237–39, 250, 251, 253
 index   709

sex vs. 238–40 GISRS (Global Influenza Surveillance and

as social construct 237, 238, 253 Response System) 536–37, 539
transgender populations 66, 240, 252 GlaxoSmithKline 395
utilization of health services by 243–45 Gleneagles Declaration (2005) 5
gender blindness 246, 252–54 Global Action Plan for Influenza
gender inequality Vaccines 537
absence of effective response to 251–52 Global Action Plan for the Prevention and
economic development and 152 Control of Non-communicable
health effects of 238, 239, 243–46 Diseases 393, 635
in health workforce 246 Global Alliance for Vaccines and
organizational responses to 247–49 Immunizations (GAVI)
poverty and 152 as actor in global health politics 4, 271
structural vulnerability and 63 in agenda setting 331
gender mainstreaming 248, 250 establishment of 50, 594, 607
gender roles modernization funding for 274, 291, 401
hypothesis 242 governance structure 358
General Agreement on Tariffs and Trade on results-based financing 51
(GATT) 428–29, 433, 474, 610 strategies utilized by 597, 599
General Agreement on Trade in Services global apartheid metaphor 570
(GATS) 428, 434, 452 global burden of disease (GBD)
General Assembly. See United Nations BRICS countries and 309
General Assembly corporate influences on 375
generalism, defined 687 gender and 239, 253
generic medications measurement of 50, 454
active pharmaceutical ingredients for 312 NCDs in 108
compulsory licensing for 504, 559, Global Coordinating Mechanism
613–15, 617 for Noncommunicable Diseases
Doha Declaration on 614–15 (GCM/NCD) 639, 640
expenditures on 607 Global Fund to Fight AIDS, Tuberculosis and
production centers for 311 Malaria (GFATM)
Revised Drug Strategy on 610 as actor in global health politics
TRIPS on 48, 271, 333, 353, 360, 475, 559 218, 270
Geneva Declaration (1948) 688 in agenda setting 331
genocide 153, 499 corruption in fund disbursement 9–10
German, Danielle 66 country coordinating mechanism
GFATM. See Global Fund to Fight AIDS, of 314–15
Tuberculosis and Malaria establishment of 50, 93, 110, 116n2, 134,
GHD. See global health diplomacy 286, 503
GHG. See global health governance evaluation of 114
GHSI (Global Health Security expenditures of 607
Initiative) 134, 517 funding for 274, 291, 333, 401, 560, 563
Gill, Bates 113 generic medication purchases by 615, 616
Gill, Stephen 268, 271, 400, 445 governance structure 358
Gilmore, Anna 676 negotiation of health issues by 105
Gilson, Lucy 90, 112 (RED) project contributions to 93–94,
GISN (Global Influenza Surveillance 413–17
Network) 188, 533, 534, 536 on results-based financing 51
710   index

global health history of cooperation on 19–21

agenda setting for. See agenda setting investment-oriented approach to 49–51
biosecurity as risk to 183, 185–86, 191–92 philanthropy in 410, 416, 421–22
climate change impact on 223 politics of 172, 272–76
conditionalities of 46 power distribution in 10, 273–74
critical thinking in. See critical thinking rational actor model of 65
definitions of 3, 38, 41 reform of structures for 643
diplomacy and. See global health risk-based mentality to 165–66
diplomacy sector-specific 273–74
in economic growth 3, 19, 26, 50 shifts in 92–93, 165–66, 266–69
Enlightenment influences on 86, 87 vulnerability of norms of 53
governance of. See global health global health politics
governance as academic discipline 1–2, 4, 551
human security and 143–44, 149–57 of access to medications 605–6, 612–22
infectious diseases and 155–56 actors involved in 4, 33, 270–71
international development effects on 218, agenda setting in. See agenda setting
221–23, 229 business sector in. See business sector
international health compared to 104 civil society and. See civil society
military and. See military assistance organizations
origins of 38, 125, 170, 189 critical security studies and 170–73
philanthropy and. See philanthropy defined 3–4
politics of. See global health politics development of 4–7
poverty and 51, 154–55 of epidemic response 91
selectivity in 38, 39, 49–51 future outlook for 9–11
violence and 150–54 gender in. See gender
global health diplomacy (GHD) 103–16 of globalization. See globalization
by BRICS countries 303, 306, 318 of healthcare reform. See healthcare reform
defined 104–5 of inequality. See health inequality
drivers of 112–14 interdisciplinary nature of 7–8, 10–11
evaluation of 114–15 power in. See power
FCTC in 672 representation in 94–95, 165
future outlook for 115–16 states and. See states
health and foreign policy link in 105–14 Global Health Security Initiative (GHSI)
instruments of 111–12, 112b 134, 517
nonstate actors in 113 Global Influenza Surveillance and Response
origins of 105 System (GISRS) 536–37, 539
overview 103–4 Global Influenza Surveillance Network
as soft power tool 110–11, 306 (GISN) 188, 533, 534, 536
global health governance (GHG) 265–76 globalization
architecture of 270–72 antiglobalism 39, 53, 379
authority types in 275 climate change and 6, 222–23
BRICS countries’ engagement with 302–7, criticisms of 10, 48, 221, 267
311, 317–19 definitions of 37, 39–40, 217, 220, 291
business sector in 398–400 determinants of health and 40, 47, 65
civil society organizations in 373–74, 378 disease and 125, 128, 171, 268, 270, 592–96
corporate influence in 375 economic. See economic globalization
criticisms of 9–10, 265–66 food industry and 392–93, 395, 476–77
 index   711

health policy agenda and 103 Goldade, Kathryn 63

inequality and 220–22 good governance 145, 147, 313, 455, 460
integrative and ideational aspects of 37–42 Goodin, Robert E. 170
neo-liberal. See neo-liberal globalization Gore, Al 557
of pharmaceutical sector 5, 622 Gostin, Lawrence O. 133, 643
primary healthcare and 41 government-organized NGOs
privileged position of business in 289 (GONGOs) 368
societal effects of 3 GPA (Global Programme on AIDS) 352,
trade liberalization and 6, 470 358–59, 556
transformationalist approach to 40 GPEH (global political economy of
waves of 220 health) 470, 479–80
global North GPEI (Global Polio Eradication
debt crises triggered by 88 Programme) 596
development discourse used by 217 GPHIN (Global Public Health Information
economic shifts in 478 Network) 517–19
Great Transformation and 219 Graham, E. R. 352
knowledge production in 89–90 Gramsci, Antonio 72, 92, 229
politics of epidemic response in 91 Grant, James 31, 49, 326, 506, 595
Global Outbreak Alert and Response Graunt, John 237
Network (GOARN) 266, 270, 275, 307 Great Depression 447
Global Polio Eradication Programme Great Divergence 217, 219–20
(GPEI) 596 Great Transformation 217, 219–20
global political economy of health greedy bastards hypothesis (GBH) 67
(GPEH) 470, 479–80 Greener, Robert 155
Global Programme on AIDS (GPA) 352, Greer Murphy, Amy 66
358–59, 556 Griffin, Jeffrey A. 143
Global Public Health Information Network Group of Seven/Eight (G7/G8)
(GPHIN) 517–19 Gleneagles Declaration 5
global South Global Health Security Initiative from 517
development assistance for 107 health agenda of 105, 134, 272, 286
economic shifts in 478 membership in 116n1, 303–4, 525n2
Great Transformation and 219 Muskoka Initiative on Maternal, Newborn
health security in 42 and Child Health 108
health surveillance in 42 in transnational state 290
incentives for investment in 415 Group of Twenty (G20) 105, 134, 272, 303, 306
international development and 217, 218, GTSS (Global Tobacco Surveillance
224, 225 System) 631, 674
postcolonial politics of 41 Guérin, Camille 585
poverty reduction strategies in 48
South-South partnerships 111, 313 H
Global Tobacco Surveillance System Habermas, Jürgen 162
(GTSS) 631, 674 HAI (Health Action International) 356,
global warming. See climate change 608–9
GOARN (Global Outbreak Alert and Haiti earthquake (2010) 152, 517
Response Network) 266, 270, 275, 307 Halperin, Sandra 291
GOBI interventions 30–31, 49, 450 Hammonds, Rachel 493
Goehler, Gerhard 72 Hankivsky, Olena 241
712   index

Hanlon, Gerard 398 defined 60

Hanrieder, Tine 347, 352, 355 determinants of 59, 61
hantavirus 155 intersectionality and 68–70, 73
hard power 72, 104, 110 literature review 60–61, 70–73
Harman, Sophie 271, 421 measurement of 60
Harmer, Andrew 217, 302, 304, 310 in mortality rates 59
Hart, Tom 284 NCDs and 630–31
Hartzell, Caroline A. 472 political science of 285
Haugaard, Mark 72 power in relation to 62–67, 70–73, 469
Hawkes, Sarah 237 in trade agreements 110
Hawkins, Benjamin 427, 437 health personnel, guidelines for international
Health Action International (HAI) 356, recruitment of 112b
608–9 health policy triangle 90, 112
health and healthcare health security 123–38
in colonial era 20, 43, 49 allocation of resources to 133–34
culture for 552 antimicrobial resistance and 130–32, 134
definitions of 149–50 benefits of securitizing health 132–34
determinants of. See determinants of health biosecurity practices as 186–89
economics of 564 bioterrorism and 103, 129–30, 132
foreign policy in relation to 105–14 collaboration with public health
global. See global health actors for 133
as human right. See human rights construction of threats to 127–32
in ideologies of development 87–88 critical security studies on 164–70, 173
inequality in. See health inequality defined 186
in neo-liberalism 33, 37, 41, 43, 88 disease and insecurity 125–27
primary. See primary healthcare Ebola virus and 103, 123–24
privatization of 46, 47, 222, 243, 451, 452 emerging infectious diseases and 127–28,
reform. See healthcare reform 133, 543
security and. See health security global health diplomacy and 113
universal. See universal health coverage in global South 42
healthcare reform 445–61 high politics of 41
context for contemporary debates HIV/AIDS and 94, 103, 106, 128–29,
on 446–49 133–34, 148–49
neo-liberalism and 450–55, 461 human rights and civil liberties
overview 445–46 issues in 135
post-global financial crisis 456–61 human security in relation to 150, 543
primary healthcare in 449–53 in medicalization of security 126, 131–33
socialism and 448–49 opportunity costs of 137–38
universal health coverage in 316 political attention on 133–34, 166–67
Washington Consensus and 454, 456 prioritizing risks and responses for 186–89
Health for All (HFA) movement 445, 449, responses generated by threats to 132
591, 608–9 sacrifices for 134–38
health inequality 59–76 travel and trade restrictions for 136–37, 165,
analytical frameworks for 74–75 189–91, 207
capabilities approach to 70 vulnerabilities in 167–70
cosmopolitanism on 113–14 Hearn, Jeff 203
critical race theory on 67–68 hegemonic power 72
 index   713

Hein, Wolfgang 616 as security threat 94, 103, 106, 128–29,

Helsinki Declaration (1964) 688 133–34, 148–49
Henderson, Donald 29, 594, 595 stigma associated with 32, 66, 94, 167, 556
hepatitis B 206, 598, 599 treatment for. See antiretroviral therapies
hepatitis C 616, 618, 619 Ho, Vivian 416
Heymann, David 6–7, 188 Hoddie, Matthew 472
HFA (Health for All) movement 445, 449, Holbrooke, Richard 129
591, 608–9 Holden, Chris 427, 437
H5N1 (avian influenza) 128, 184–85, 188, Holm, Johannes 585
535–37 Holmes, Seth M. 63
Hickel, Jason 230 Holt, Timothy H. 507
high-income countries (HICs) homosexuality 32, 503, 553, 555–56, 559, 565
development assistance from 108, 109 H1N1 (swine flu)
healthcare financing in 283 emergence of 537–38
influenza research in 185, 532, 534, 535 as impetus for addressing global health
intersectionality in 69 issues 103
military assistance from 200 monopolization of vaccines for 91, 188
NCDs in 630 PHEIC declaration for 357
TRIPS rules and 72 response to 269, 538, 541–42
vertical campaigns and 26 as security threat 128
Hill, Bradford 661 travel restrictions for 136, 331
Hindmarsh, Richard 419 Horkheimer, Max 91, 162
historical materialism 66–67 Horton, Richard 39, 41–42, 376
HIV/AIDS 551–65. See also Global Fund to Hoy, Chris 285
Fight AIDS, Tuberculosis and Malaria H7N9 (avian influenza) 155
advocacy for 268, 272, 565 Huang, Yanzhong 301, 302
agenda setting for 329–31, 333, 334 Hudson, Ian 65
developmental assistance for 286–87 humanitarianism
emergence of 32, 88, 551–54, 612–13 budget allocation for 41–42
epidemiological scenarios for 556–57 colonialism justified by 20
funding for 560, 561f, 563–64 development aid as 4
gendered nature of 562 health policy as 103, 106, 579
global response to xiii–xiv, 5, 32, 93, 129 as improvement project 87
governance of 271, 273, 276 military assistance with 197, 199–201
human rights and 135, 331, 503–4, 508 new humanitarianism 5
innovation resulting from 89 human rights 493–508
intersectionality and 69, 70 in agenda setting 329, 330, 333–35
Jaipur paradigm on 558–59 citizens’ rights vs. 495–500, 507–8
mortality rates 114 civil 494–95, 497–501
politicization of 554, 556, 557, 564–65 claimability condition for 496–98
poverty and 155, 552, 559 descriptive approach to 494, 495, 503–7
pre-exposure prophylaxis for 562 freedoms vs. entitlements 497, 500–501, 508
prevention strategies 555–56, 561–62 gender equality 238
public health approach to 552, 554–55 health security and 134–35
quarantines for 135 HIV/AIDS and 135, 331, 503–4, 508
Resolution 1308 on xiii, 110, 271, 557–58 ICESCR. See International Covenant on
risk mentality towards 165 Economic, Social, and Cultural Rights
714   index

human rights (Continued ) Illich, Ivan 552, 565n2

international norms for 494 IMF. See International Monetary Fund
as leverage for NGOs 501–2, 508 immanent (unintentional) development 217,
medication access and 4, 42, 544 218–23, 229
NCDs and 643 immigrant populations
normative approach to 494–502 fear-mongering rhetoric targeting 53
PAHO on 23 framing as health risks 171
political 494–95, 497–501 multilevel governance for 274
in postcolonial society 43–44 welfare reforms impacting 66
UDBHR. See Universal Declaration on immunizations. See vaccinations
Bioethics and Human Rights Imperial Tobacco 663
UDHR. See Universal Declaration of income inequality 47, 229, 456
Human Rights India. See also BRICS countries
WHO on 24, 44 access to healthcare in 460
Human Rights in International Relations agenda setting in 335
(Forsythe) 499 bubonic plague in 32, 152
human security 143–57 in colonial era 220
components of 144, 145 development assistance from 303,
global health and 143–44, 149–57 308–11, 313
health security in relation to 150, 543 gender inequality in 70, 239, 243
infectious diseases and 155–56 health promotion activities in 66
national security in relation to 145–46, 157 hysterectomy in 64
overview 143–44 implementation of WHO recommendations
poverty and 152, 154–55 in 115
state capacity and 147–49, 148f, 155–57 influenza pandemics in 533
UN Commission on 147, 149–56, 158n1 pharmaceutical sector in 311–12, 597,
UNDP framework for 144–46 613–14
violence and 150–54 population control in 28, 356
social indicators in 282
I state-centric approach in 314
ICAP (International Center for Alcohol tobacco use patterns in 241
Policies) 391–92 vaccination campaigns in 587–88,
ICCPR (International Covenant on Civil and 590, 598
Political Rights) 494–95, 497–501 Indonesia
ICESCR. See International Covenant on cigarette flavouring dispute with
Economic, Social, and Cultural Rights US 429–33
ICPD (International Conference on Population decentralization in 283
and Development) 31, 248, 333, 356 demands for access to vaccines 42, 188,
ICRC (International Committee of the Red 536, 544
Cross and Red Crescent) 199 on FCTC 673
ideational power 4 tsunami in (2004) 200
IFPMA (International Federation of industrial epidemics 390–91, 477, 632
Pharmaceutical Manufacturers inequality
Associations) 594, 609–10, 616 economic 284, 370, 390, 478
IGOs. See intergovernmental organizations gender. See gender inequality
IHRs. See International Health Regulations globalization and 220–22
 index   715

health. See health inequality intellectual property protection. See also

income 47, 229, 456 Agreement on Trade-Related Aspects
infectious diseases of Intellectual Property Rights;
development assistance for 108 patent protections
emerging. See emerging infectious diseases copyright and 353
global health and 155–56 harmonization of 475
global surveillance of 91, 133, 187–88 medication access and 47–48,
human security and 155–56 287–88, 396
poverty and 154 as policy tool 617
re-emerging 32–33, 88, 535, 543 public goods vs. 573
reporting. See outbreak reporting regulatory conflict over 359–60
as security threat 127–28, 179, 543 transnational network influence on 290
social and economic impact of 132 intentional (planned) development 217–18,
social-distancing measures for 132, 135, 224–29
190, 542 intergovernmental organizations
transboundary risks from 6, 128 (IGOs) 347–61. See also public-private
travel restrictions in response to 136–37, partnerships
189–91 on access to medications 617
influenza. See also influenza pandemics as actors in global health politics 4, 249
avian 128, 155, 184–85, 188, 535–37 autonomy of 349–52
dispersal of research on 185–86, 532 competition among 358
global surveillance of 187–88, 533, 534, dynamics of change in 354–60
536, 545 Ebola outbreak response by 155
seasonal 532, 534, 540, 541 global health diplomacy by 105
vaccination for 186, 188–89, 531–41, 544–45 influence on member states 353–54
influenza pandemics 531–45 interconnectedness of 360, 361
Asian (1957) 533, 541 NGOs compared to 347
debates on response mechanisms 89 overview 347–48
economic consequences of 542 power of 348–54
fears regarding 6, 187, 531, 535–36 roles and responsibilities of 348–49
governance arrangements for 531, 535, Intergovernmental Panel on Climate Change
544, 545 (IPCC) 223
history of 532–34 International AIDS Society 4, 270
norms and ideas shaping policy on 539–44 International Bank for Reconstruction and
preparedness for 132, 185, 188–89, 306, Development 224
535–44 International Center for Alcohol Policies
securitization of 543 (ICAP) 391–92
Spanish (1918) 532, 534, 539–40, 543 International Committee of the Red Cross
swine flu. See H1N1 and Red Crescent (ICRC) 199
informed consent 198 International Conference on Population
Ingram, Alan 8, 85, 286 and Development (ICPD) 31, 248,
Institute of Medicine (IoM) 127, 267–68, 535 333, 356
institutional capacity of states 147, 149 International Conference on Primary Health
institutional power 72, 74, 355 Care 30
Intellectual Property Committee International Covenant on Civil and Political
(IPC) 396 Rights (ICCPR) 494–95, 497–501
716   index

International Covenant on Economic, Social, good governance lexicon in 455

and Cultural Rights (ICESCR) 106, 144, on influenza pandemic preparedness 535,
494, 497–502, 637 538–39
international development 217–30 policymaking influences 92
assistance for. See development assistance response to debt crises 38, 45–46,
conceptualizations of 217 88, 471
contemporary goals of 226–29, 226t, 228t structural adjustment programs 38, 46,
economic. See economic growth and 221, 353, 371, 471–73
development in transnational state 290
future outlook for 229–30 International Organization for
gender policies in 250 Standardization (ISO) 398–99
immanent (unintentional) 217, International Organization of Consumer
218–23, 229 Unions (IOCU) 609
implications for global health 218, international relations (IR). See also foreign
221–23, 229 policy
planned (intentional) 217–18, 224–29 critical thinking in 89
International Ethical Guidelines for in global health politics 7–8
Biomedical Research Involving Human on health security 164–65
Subjects 688 high/low politics in 5, 106
International Federation of Pharmaceutical human rights in 499
Manufacturers Associations philanthropy and 410
(IFPMA) 594, 609–10, 616 post-positivism in 162
International Federation of Red Cross realist theory of 91, 112–13, 493
Societies 22 securitization theory in 94–95, 134
international health security dilemmas in 181, 183
as academic discipline 25 states as political units of 40
economic growth and 19, 26, 34 violence as conceptualized in 150
global health compared to 104 International Sanitary Conferences 20–21,
goals for 29, 45, 224 126, 170, 172, 266, 348, 389
origins and evolution of 19, 267 Internet surveillance response programs
vertical approaches to 44, 49 (ISRPs) 514–19, 521, 523
International Health Regulations (IHRs) interpersonal violence 151, 152, 157
compliance with 307 intersectionality 68–70, 73, 240–41
health security and 126, 136, 187 investor-state dispute settlement (ISDS) 399,
on interference with international traffic 436–37, 440, 477
and trade 190 IOCU (International Organization of
legacy of 34 Consumer Unions) 609
on outbreak reporting 136, 513–16, IoM (Institute of Medicine) 127, 267–68, 535
522–24 IPC (Intellectual Property Committee) 396
on PHEICs 166, 187 IPCC (Intergovernmental Panel on Climate
revisions to 103, 113, 134, 306, 348 Change) 223
state-centric approaches to 314 Iqbal, Zaryab 151
WHO mandate in 25, 351 IR. See international relations
International Monetary Fund (IMF) Iraq, tailgate medicine in 208–10
bureaucratization and 350 Irwin, Rachel 114, 115
development agenda 225 ISDS (investor-state dispute settlement) 399,
establishment of 224 436–37, 440, 477
 index   717

ISO (International Organization for Kevany, Sebastian 114

Standardization) 398–99 Keynes, John Maynard and Keynesian
isolationist policies 22, 136 economics 230, 447, 448, 456
ISRPs (Internet surveillance response Khazatzadeh-Mahani, Akram 103
programs) 514–19, 521, 523 Khrushchev, Nikita 25
Ivins, Bruce 130 Kickbusch, Ilona 7, 106–7, 269, 271
Iyer, Aditi 69, 70 Kim, Jim Young 47
Kingdon, John W. 112, 113, 335, 337
J Kirton, John 305
Jaggar, Alison M. 247 Koblentz, Gregory 180
Jaipur paradigm 558–59 Koch, Robert 583, 585
Japan Tobacco International (JTI) 395, Kochi, Arata 418
663, 669 Koplan, Jeffrey P. 42
Jenkins-Smith, Hank C. 338 KraftHeinz 395
Jenner, Edward 583, 584 Krause, Keith 162
Johnson, Anne M. 329 Krieger, Nancy 469
Joint United Nations Programme on HIV/ Kulik, Julia 305
AIDS (UNAIDS)
on access to HIV/AIDS treatment L
xiii, 333 Labontè, Ronald 93, 103, 112, 397
epidemiological scenarios developed Lake, David 471
by 556–57 Lakoff, Andrew 42–43
establishment of 32, 273, 358–59, 557 Lancet Commission 10, 50
expert authority of 275 Latin America
harassment and bullying within 10 in colonial era 220
as meta-organization 361n1 conditional cash transfer programs
political accountability mechanisms in 285
and 637 epidemics in 20–21, 32
Jones, Bryan D. 338 pharmaceutical sector in 312
Joseph, Jonathan 268–69 public health services in 88
JTI (Japan Tobacco International) 395, social movements in 368
663, 669 tobacco markets in 663
juveniles. See children and adolescents vaccination campaigns in 587
Latour, Bruno 97–98
K Lauridsen, Ernst 609
Kaddar, Miloud 600 Laws, Edward 295
Kaldor, Mary 368, 379 Leach, Melissa 269
Kamradt-Scott, Adam 197, 329, 531 League of Nations Health Organization
Kanavos, Panos 402 (LNHO) 22, 23, 34, 348, 586
Kant, Immanuel 86, 95, 97 Lederberg, Joshua 127, 128, 580
Kaposi’s sarcoma 32, 553 Lee, Kelley 1, 106, 109, 114, 164, 306, 387, 661
Kapstein, Ethan B. 331 Lee Jong-wook 518–19
Kelsall, Tim 284 legitimacy, of bioethical frameworks
Kennedy, Jonathan 217 687–90, 694
Kenny, Katherine E. 51 Lencucha, Raphael 332
Kerrigan, Deanna 66 Li, Tanya Murray 87
Keshavjee, Salman 222 Liang, Brian A. 643
718   index

life expectancy. See also mortality rates Mahler, Halfdan

cosmopolitanism on differences in 113 medicine policy conference organized
gains in 458, 627, 628 by 609
gender differences in 237–39, 250, 251, 253 on primary healthcare 30, 31, 44, 49, 608
globalization and 221 on vaccination programs 592, 594
in Great Transformation 220 on women’s health needs 247–48
neo-liberal policies and 222, 454 malaria. See also Global Fund to Fight AIDS,
socio-economic status and 59, 152 Tuberculosis and Malaria
lifestyle diseases 154, 156, 664 agenda setting for 328
Liu, Joanne 273 Alexander the Great and 198
LNHO. See League of Nations Health drug-resistant 611
Organization economic benefits of reducing 53
Lopez, Ana Mendez 629 eradication campaigns 26–27, 31, 350,
Lorber, Judith 238 589, 596
Lorillard 431 Exxon Mobil Malaria Initiative 395
low- and middle-income countries (LMICs) as re-emerging disease 88
collapse of public health infrastructure in 33 Roll Back Malaria initiative 51
debt crises in 288, 471 males. See gender
development assistance for 109, 619 Malthus, Thomas 219, 230
dispute settlement mechanisms for 433 Mann, Jonathan 32
fiscal burden of foreign debt in 225, Marburg virus 155
288, 448 maritime sanitation rules 19, 20
food industry in 476 Marshall Plan 224
green revolution in 23 Martin, Emily 171
healthcare financing in 283 Marx, Karl and Marxism
HIV/AIDS funding in 563 on capitalism 219
influenza research as benefit for 185 Communist Manifesto 229
intersectionality in 69 critique of political economy in 92
military assistance in 200, 208 historical materialism in 66–67
NCDs in 59, 108, 630 on metabolic rift 222
population control in 27–29 neo-Marxism 65–67
primary healthcare in 449, 450, 456 on power relations 65–67
R&D activities in 621 on revolutionary movements 95
rural hygiene in 22 Ricoeur on 96
Sustainable Development Goals for 228 on universal human emancipation 96
tobacco use in 390–91 material power 4, 62, 73, 355, 402
TRIPS rules and 72 Matthews, Kirstin R. W. 416
vaccinations in 536, 537, 598–99 Mbeki, Thabo 558
WHO regional offices in 24 McCollum, Rosalind 69–70
Lu, Chunling 283 McCoy, David 367, 420–21
Lush, Louisiana 327, 331–32 McDonald, Matt 164
McGrady, Benn 439
M McInnes, Colin 1, 109, 164, 165, 265, 329
MacFarlane, S. Neil 146 McKee, Martin 186
Mackenzie, Catriona 169, 170 McMichael, Tony 223
Mackey, Tim K. 643 MDGs. See Millennium Development Goals
Magnusson, Roger 627 Mead, Walter Russell 478–79
Maher, Anthony 633, 634 measles 594, 596, 598
 index   719

MEDCAPs (Medical Civic Action militant anthropology 480

Programmes) 200, 208–10 military assistance 197–211
Médecins sans Frontières (MSF) civil-military cooperation 199–201,
as actor in global health politics 4, 33 205–8
disease surveillance networks of 517 disease prevention efforts 198
Drugs for Neglected Diseases Initiative with Ebola virus 201, 204–6
from 572 foreign 201, 204–6
Ebola outbreak assistance from 204, in humanitarianism 197, 199–201
205, 265 long-term vs. short-term gains 207,
establishment of 33 209, 211
opposition to military-humanitarianism in natural vs. complex emergencies
199 200–201, 210
principled authority of 275 opportunity costs of 200, 208
medical anthropology 62, 63, 73, 353 opposition to 199–200
Medical Civic Action Programmes overview 197–98
(MEDCAPs) 200, 208–10 with poliovirus 206–8
medical/industrial complex 453 in research and development 198–99
medicalization of security 126, 131–33 for tailgate medicine 208–10
medications. See also pharmaceutical sector with Zika virus 201–3
access to. See access to medications military capacity of states 149
antivirals. See antiviral medications Millennium Development Goals (MDGs)
ARTs. See antiretroviral therapies acceleration of progress on 326–27
Essential Medicines List 608–10, 615 access to medications and 607
expenditures on 606, 607, 619 agenda setting for 6, 329, 330, 333
generic. See generic medications funding for 106, 560
innovation in 610–12 gender components of 248
for neglected tropical diseases 572 on human right to health 494
patents for. See patent protections omission of NTDs in 571
penicillin 198, 552 as planned development strategy 218
pricing of 47–48, 290, 434 power in establishment and
resistance to. See antimicrobial resistance institutionalization of 74–75
Revised Drug Strategy 609, 610 targets of 226–27, 226t
standardization of 22 Mintrom, Michael 248
stockpiling of 130, 137, 536, 539 Money, John 237–38
vaccines. See vaccinations Montgomery, Hugh 223
Medicines Patent Pool (MPP) 616 Moody, Michael P. 409
Mejia, Raul 673 Moon, Suerie 605, 616
Memish, Zaid 522 moral relativism 687
men. See gender Morse, Stephen 127, 128
menstrual hygiene management 331, 332 mortality rates. See also life expectancy
Merck 578 alcohol use and 242
Messineo, Carol 147 for children 59, 109, 152, 221, 227
metabolic rift 222 of Ebola outbreak 204
microbicides 562, 565n5 for HIV/AIDS 114
Middle East respiratory syndrome for industrial proletariat 219
(MERS) 128, 518, 520–24, 525nn5–6 for NCDs 59, 627, 628t, 632
middle-income countries. See low- and in refugee camps 151
middle-income countries from tobacco use 242, 661
720   index

most-favoured nation principle 429 Washington Consensus and 38–39, 45–47,

MPP (Medicines Patent Pool) 616 220, 225
MSF. See Médecins sans Frontières neo-liberalism. See also neo-liberal
Mukherjee, Suroopa 169 globalization
multiple-streams model 112, 335, 337–38 civil society organizations in relation
Murphy, Tim 124 to 372, 377
Mykhalovskiy, Eric 166 critique of 92, 221–22
economic policies in 37, 41, 45, 220
N erosion of professionalism in 457
NAFTA. See North American Free Trade framing of public health challenges in 632
Agreement healthcare reform and 450–55, 461
Nakajima, Hiroshi 31, 32, 672 market policies in 37, 41, 427
Narasimhan, Vasant 136 policy convergence under 291
National Health Service (NHS) 447–48, 586 shock therapies in 221, 225, 472
National Institutes of Health (NIH) 184, socialism vs. 445, 448
594, 611 structural adjustment programs and 38,
nationalism 10, 39, 369, 379, 441 46–47, 371, 471–73
National Philanthropic Trust 373–74 of Washington Consensus 38–39, 45–47,
national treatment principle 429 220, 225
Naylor, Thomas 471 neo-Marxism 65–67
NCD Alliance 376, 633, 646 neorealist theory 330
NCDs. See non-communicable diseases Nestlé 392, 395
neglected tropical diseases (NTDs) 569–80 New Development Bank 304
ascendance on global health agenda 334 new international economic order
defined 569 (NIEO) 44, 46, 456, 505–6, 591
Global Plan to Combat NTDs 571–72 New Washington Consensus 49–52
global politics of 570, 579, 580 Ng, Nora Y. 301
investments in 573, 578 NGOs. See non-governmental organizations
omission in MDGs 571 NHS (National Health Service) 447–48, 586
poverty and 569, 571, 580 nicotine. See tobacco use
prevalence of 569, 579 Nie Jing-Bao 696
public-private partnerships for 578, 580 Nietzsche, Friedrich 96
summary of 573, 574–77t NIH (National Institutes of Health) 184,
in Sustainable Development Goals 579 594, 611
10/90 divide in health-related R&D Nipah virus 518
and 569, 571 Nishtar, Sania 643
neo-liberal globalization non-aligned movement 87, 449, 456
backlash against 441 non-communicable diseases (NCDs)
criticisms of 48–49, 52, 91–92 627–48
evolution of 53 access to medications for 646
global health politics and 369–70 agenda setting for 328, 632
health investments and 50–51 in BRICS countries 309
international development and 220–21 burden of 108, 629, 630, 648
merger of global health regimes and development assistance for 287, 627
39–43 economic and material support for policy
social determinants of health and 65 implementation 640–41
 index   721

emergence as global health Nuremberg Code 688

challenge 628–31 Nye, Joseph S., Jr. 72, 110
framework for analysis of global action
on 635, 636t O
global movement for action on 631–34, Obama, Barack
645–47 on antimicrobial resistance 131
governance structures for 643–44 on Ebola outbreak 123–24, 286
health inequality and 630–31 promotion of global health issues by 272
in human rights framework 636–37, 643 Obot, Isidore S. 242
industry-led resistance to policies OECD. See Organisation for Economic
on 641–42 Co-operation and Development
mortality rates for 59, 627, 628t, 632 Office International d’Hygiène Publique
normative instruments and policy (OIHP) 21, 22, 348
guidance for 393, 635–37 official development assistance (ODA) 92,
political accountability mechanisms 224, 288
and 637–39, 638t Ogata, Sadako 149–50, 154, 155, 158n1
public-private partnerships and 644–45 Ogden, Jessica 327
risk factors for 154, 628–31 Oil for Doctors Program 108
societal changes resulting from 390 older adults. See elderly populations
terminology issues 647 O’Manique, Colleen 93, 187
non-decision-making power 72 O’Neill, Jim 131
non-governmental organizations (NGOs) “One World One Health” paradigm 10, 114
as actors in global health politics 33 Ooms, Gorik 107, 493
in agenda setting 325, 332 opportunity costs
business-interest 368, 377 debt crises and 288
civil-military cooperation by 199, 206 of emergency measures in financial
competition among 52 crisis 458
exercise of power by 63 of health security 137–38
on gender mainstreaming 248 of military assistance 200, 208
government-organized 368 of NCDs 631
HIV/AIDS activism by 565 of prioritizing partnerships over
human rights as leverage for 501–2, 508 regulation 644
in human security 147 oral rehydration therapies (ORT) 30, 31,
IGOs compared to 347 49, 450
international development efforts of Orbinski, James 570–72
217, 222 Organisation for Economic Co-operation and
negotiation of health issues by 105 Development (OECD)
normative approach to human competition from China 308
rights 494–502 development assistance from 224, 226–27,
North, Douglass C. 282, 284 310, 312, 318
North American Free Trade Agreement primary healthcare in 448
(NAFTA) 107, 440, 441, 474–75, 477 promotion of economic growth by 453
Novartis 573, 618, 670 R&D investment by member countries 621
Novotny, Thomas E. 306, 669 Organisation of African Unity xiii
NTDs. See neglected tropical diseases orphan diseases. See neglected tropical
Nunes, João 161 diseases
722   index

Oslo Declaration (2007) 109 Medicines Patent Pool 616

Ostergard, Robert L., Jr. 143 prioritization of commercial interests
Osterholm, Michael 185 through 107
Ostrander, Susan 418 in research and development 4
Ottersen, Ole Petter 478 path dependency 9, 252, 254, 355–57
outbreak reporting 513–24 PA (principal-agent) theory 349–52
IHRs on 136, 513–16, 522–24 patriarchy 90, 243, 246, 248, 251
incentives for 136 PATRIOT Act of 2001 163
ISRPs in 514–19, 521, 523 Payton, Robert L. 409
by nonstate actors 513–16, 519–24 Peeters, Silvy 676
timelines for 513 penicillin 198, 552
transparency in 516, 522 People’s Health Movement (PHM) 356, 372,
377, 505
P PEPFAR. See US President’s Emergency Plan
Pacific Island countries and territories for AIDS Relief
(PICTs) 629–30 PepsiCo 395
Packard, Randall 44–45, 49, 506 Persad, Govind C. 562, 563
Pakistan, polio eradication efforts in 206–8 Peterson, Susan 351
Pan American Health Organization Pfeiffer, James 63
(PAHO) 23, 24, 595 pharmaceutical sector. See also medications
Pandemic Emergency Financing Facility advocacy groups in 356, 376
359, 542 in BRICS countries 311–12, 318, 597
pandemic fatigue 538 consolidation of 621
Pandemic Influenza Preparedness Framework economic interests of 330–31
(PIPF) 185, 188–89, 306, 536–37, 544 engagement with PPPs 396
pandemics on Essential Medicines List 609–10
controlling 459 globalization of 5, 622
defined 20 ISDS provisions for 477
preparedness planning for 132, 137 marketing code for 609
Parkhurst, Justin O. 329 PIPF benefit sharing process for 536–37
participant observation 63, 71 profitability of 607
partnerships. See also public-private R&D activities in 415, 571, 621
partnerships tobacco control initiatives supported
defined 388b by 670
prioritizing over regulation 644 in TTIP negotiations 289
South-South 111, 313 PHC. See primary healthcare
Partzsch, Lena 411 PHEICs. See public health emergencies of
Pasteur, Louis 583, 584 international concern
patent protections philanthrocapitalism 94, 377, 416
activism regarding 475 philanthropy 409–22
for antiretrovirals 613–15 advantages in global health 414–17
as barriers to access 396 components of 409–10
in Drugs for Neglected Diseases consumer-driven 413–14
Initiative 572 corporate capture of 367
economic globalization and 593 criticisms of 94, 417–21
in free trade agreements 47, 271, 353 defined 409
in global health agenda setting 333 development assistance and 411–13
 index   723

in global health governance 410, 416, global surveillance systems 518–19

421–22 outbreak reporting 517
international relations and 410 PHEIC declaration for 166
lack of oversight and accountability 420–21 vaccination for 206–8, 583, 588
medical 34 political capacity of states 147
performance-based models 374 political determinants of health 62
power dimensions of 410–11, 418, 422 political economy
in public-private partnerships 39 critique of 91–93
Philip Morris International (PMI) future research directions 478
Foundation for a Smoke-free World good governance lexicon in 455
initiated by 642, 676 of health 64–65, 372, 469–77, 479–80
harm-reduction strategies 677 Keynesian 448
influence on tobacco laws 674 market mechanisms in governance of 447
manifesto for smoke-free future 394 political-cultural analysis vs. 38
on market expansion 663 of redistribution 285
pack marker system 676 structural adjustment programs
shares of menthol market 431 and 471–74
on WHO tobacco control efforts 664 of trade 474–77
WTO disputes and 434, 437 political rights 494–95, 497–501
PHM (People’s Health Movement) 356, 372, political science
377, 505 conceptualizations of power in 64–65
PICTs (Pacific Island countries and in global health politics 7, 8
territories) 629–30 of health inequality 285
Piketty, Thomas 458 of social determinants of health 285
Pillay, Yogan 507 political settlements 284, 479
Pillinger, Mara 356 politics. See also global health politics
Piot, Peter xiii, 6, 32, 129, 133–34, 155, 503, 558 of global health governance 172, 272–76
PIPF. See Pandemic Influenza Preparedness high/low distinction in 5, 41, 106
Framework of neo-liberalization 38
Pisani, Elizabeth 283 planetary 10
place-based stigma 66 of representation 94–95, 165
plague. See bubonic plague of security 162–64
planetary boundaries 223 population control 27–29, 356
planetary politics 10 populist movements 10
planned (intentional) development 217–18, post-positivism 162
224–29 Poteat, Tonia 66
pluralism, in bioethical frameworks poverty
687–93, 696 access to healthcare and 461
plurilateral summit institutions (PSIs) 303, capabilities approach to 154
305, 306 children in 153
PMI. See Philip Morris International cycle of 154, 156, 631
Pneumocystis carinii 32, 553 economic growth and 228–29
Pogge, Thomas 480 global health and 51, 154–55
Polanyi, Karl 219, 220, 229 HIV/AIDS and 155, 552, 559
poliovirus human security and 152, 154–55
agenda setting for 328, 594 moral responsibility for 480
eradication campaigns 206–8, 415, 595–96 NCDs and 154, 631
724   index

poverty (Continued) power cube framework 74

neglected tropical diseases and 569, PPPs. See public-private partnerships
571, 580 praziquantel 330
prevalence of 370 pre-exposure prophylaxis (PrEP) 562
reframing as domestic issue 479 prejudice. See discrimination; stigma
as social determinant of health 285 prescription drugs. See medications
strategies for reduction of 5, 6, 48, 285 Price-Smith, Andrew 125, 132
women in 153–54 primary healthcare (PHC)
Poverty Reduction Strategy Programs Alma-Ata Declaration on 30, 44–47, 51,
(PRSPs) 471 224–25, 315, 329, 371
power in BRICS countries 315
agency forms of 61, 65, 71–73 centrality to social determinants of
analytical frameworks for 74–75 health 456
anthropological perspective on 62–64, 73 civil society organizations in promotion
asymmetries related to 291, 470, 478 of 371–72
biopower 95–96 defined 462n2
compulsory 74 globalization and 41
conceptualizations of 61–62, 71–72, 110 GOBI interventions for 30–31, 49, 450
conflictual 72 in healthcare reform 449–53
critical race theory on 67–68 for human security 145
dispositional 72 in new international economic order
epistemic 72 505–6, 591
in global health governance 10, 273–74 in postcolonial society 43, 44
hard 72, 104, 110 principles of 449
health inequality in relation to 62–67, selective. See selective primary healthcare
70–73, 469 vaccination programs integrated
hegemonic 72 into 591–92
ideational 4 vicissitudes of 29–31
institutional 72, 74, 355 principal-agent (PA) theory 349–52
of intergovernmental principled authority 275
organizations 348–54 privacy issues. See confidentiality
intersectionality and 68–70, 241 productive power 72, 74
literature review 70–73 professionalism, erosion of 457
material 4, 62, 73, 355, 402 Project Cerberus 672
non-decision-making 72 Project Last Mile 397
philanthropy and 410–11, 418, 422 ProMED 517–19, 521–23
in political science 64–65 protectionism 441, 453, 593
productive 72, 74 PRSPs (Poverty Reduction Strategy
in securitization theory 94–95 Programs) 471
smart 104, 115 PSIs (plurilateral summit institutions) 303,
sociological perspective on 65–67, 73 305, 306
soft 72, 104, 110–11, 114, 306, 635 public goods 271, 445, 452–53, 572–73, 612
sources of 73 public health emergencies of international
structural 61, 65, 71–74 concern (PHEICs) 165–66, 187, 190,
symbolic 72 357, 513
transitive 72 public-private partnerships (PPPs)
of transnational corporations 369, 388 as actors in global health politics 4, 249, 271
 index   725

in agenda setting 331 relativism, in bioethical frameworks 687–89,

as coordinating mechanisms 51 692, 696
corporate social responsibility and reporting outbreaks. See outbreak reporting
396, 397 representation politics 94–95, 165
defined 396, 578 research and development (R&D)
emergence of 370, 373, 401 investment in 415, 573, 578, 607–8, 621
GISN transformation to 536 military assistance with 198–99
global health investment by 39, 50, 225 non-profit models for 619
for health financing 452 patent protections and 4
NCDs and 644–45 in pharmaceutical sector 415, 571, 621
for neglected tropical diseases 578, 580 private sector support for 401, 412, 611
for product development 607–8, 612, 619 reform of global system for 620
for vaccinations 593–94, 596 10/90 divide in 569, 571, 612
punctuated equilibrium theory 335, 338 for vaccines 532, 539, 593, 597
resistance to medications. See antimicrobial
Q resistance
quantitative easing 457 Resolution 1308 (UNSC) xiii, 110, 271, 557–58
Responsibility to Protect agenda 5, 272, 499
R Revised Drug Strategy (RDS) 609, 610
racism 63, 67 Ricardo, David 219, 230
Rajchman, Ludwik J. 22 Ricoeur, Paul 96
Rancière, Jacques 97–98 risk-based mentality 165–66
R&D. See research and development R.J. Reynolds (RJR) 431
Rao-Gupta, Geeta 254 Robinson, William I. 290, 479
rape 153 Rockefeller, John D. 23, 390, 420
Raphael, Dennis 65 Rockefeller, John D., Jr. 410
rational actor model 65 Rockefeller, Nelson 410
rational institutionalist approach 350, 353 Rockefeller Foundation
Rawls, John 247 as actor in global health politics 4
Raworth, Kate 223, 230 establishment of 22, 390
RDS (Revised Drug Strategy) 609, 610 International Health Division 410, 415–20
Reagan, Ronald 28, 47, 220, 556 medical objectives of 23, 30
realist theory of international relations 91, neglected diseases initiative 611
112–13, 493 on planetary health 10
Reddy, K. S. 269, 271 population control policies 356
(RED) project 93–94, 413–17 on primary healthcare 49, 372
Reed, Walter 21 Trading Tobacco for Health Initiative 674
re-emerging infectious diseases 32–33, 88, Rodan, Gary 379
535, 543 Rodriguez, Mariela A. 330
reflexive analysis 68, 75 Roemer, Ruth 666, 670
refugee camps 151 Rogers, Wendy 169, 170
regulatory capitalism 642 Roll Back Malaria 51
regulatory cooperation mechanisms Rotary International 4, 373, 596
438–40 rotavirus 599
Reich, Michael R. 329, 330 Rothschild, Emma 144
Reid-Henry, Simon 42, 52 Rowden, Rick 221, 222
Reis, Andreas 460 Rowell, Andy 676
726   index

Rubin, Robert 414 Seeley, Elizabeth 402

Ruckert, Arne 103, 397 selective primary healthcare (SPHC)
Ruger, Jennifer Prah 59, 301 advocacy for 506, 507
rule-based authority 349 dominance in global health policy 371
Rushton, Simon 113, 123, 187, 271, 329–31 GOBI interventions for 30–31, 49, 450
Russell, Sarah 155 principal recipients of 249
Russia. See also BRICS countries; Soviet targeted interventions in 50
Union self-inflicted violence 151
cholera outbreak in 32, 151–52 Sell, Susan K. 275, 475
development assistance from 303, 308, Sen, Amartya 145, 149–50, 154, 155, 158n1, 282
310, 311 Sen, Gita 69, 70
in Group of Eight 116n1, 303–4 seniors. See elderly populations
military assistance from 200 September 11 attacks (2001) 6, 129, 130,
post-Soviet mortality crisis in 221 162–63, 379
privatization in 230n1 severe acute respiratory syndrome (SARS)
state-centric approach in 314 accidental infections involving 185
Rutzen, Douglas 379 agenda setting for 334
as focusing event 113
S as impetus for addressing global health
Sabatier, Paula A. 338 issues 6, 103, 307
Sabin, Albert 583, 588 outbreak reporting 136, 516, 518
Sainsbury, Diane 66 response to 5, 268, 269, 351, 535
Salk, Jonas 583, 588 as security threat 128
Sanders, David 445 travel restrictions for 269, 331, 351
SAPs. See structural adjustment programs sex (biological) 238–40
SARS. See severe acute respiratory syndrome sexually transmitted diseases (STDs). See also
Saudi Arabia, handling of MERS outbreak HIV/AIDS
in 518, 520–24 agenda setting for 327, 328, 331–32
Schaaf, M. 75 children and 153
Scheper-Hughes, Nancy 480 prevention strategies 555
Schervish, Paul G. 418 women’s risk for 152
Scholte, Jan A. 368, 372–73, 377 sexual orientation. See homosexuality
Schrecker, Ted 40, 281, 469 sexual violence 151, 153
Schuyt, Theo N. M. 410 Shaw, Leslee J. 245
Scott, Kerry 66 Shawar, Yusra Ribhi 59
SDGs. See Sustainable Development Goals Shepherd, Philip 663
SEATCA (Southeast Asia Tobacco Control Shetty, Devi 316
Alliance) 669, 674 Shiffman, Jeremy 72, 272, 325, 330, 633
The Second Sex (de Beauvoir) 237 Shue, Henry 500, 501
securitization theory 94–95, 134, 163–65 Siddiqi, Jared 350
security. See biosecurity; critical security Silva, Diego S. 685
studies; health security; human security Siracusa Principles (UN Commission on
“security as emancipation” approach 164, 168, Human Rights) 135
173 smallpox
Security Council. See United Nations Security eradication campaigns 29, 44, 224, 553,
Council 589–90, 594
security dilemmas 181, 183 International Health Regulations on 25
 index   727

population decline due to 125, 198 bubonic plague in 21

vaccination for 198, 552, 583, 584, development assistance from 303, 311, 313
589–90, 599 Ebola outbreak response by 191
smart power 104, 115 life expectancy in 221
Smith, Frank 197, 269 pharmaceutical sector in 311
Smith, James A. 250 Southeast Asia Tobacco Control Alliance
Smith, Julia 387 (SEATCA) 669, 674
Smith, Richard 106, 114, 115 Soviet Union. See also Russia
Smith, Stephanie L. 325, 330 as alternative to capitalism 447
smoking. See tobacco use in Cold War 24–25, 87
Snow, John 20 health services in 24
Snyder, Jeremy 685 HIV/AIDS disinformation campaign
social constructionism 252, 633 by 554
social determinants of health on population control 28
globalization effects on 40, 47, 65 smallpox eradication efforts 29, 589–90
horizontal approaches to 49 Spanish influenza pandemic (1918) 532, 534,
intersectionality and 240–41 539–40, 543
neglect of 459 Sparke, Matthew 37, 372, 377
political science of 285 SPHC. See selective primary healthcare
poverty and 285 SPS Agreement 428, 434
primary healthcare and 456 Sridhar, Devi 353–54, 633, 634
WHO Commission on 48, 59, 238, 470, 552 Stahn, Carsten 499
working conditions and 473 Stalin, Joseph 24
social distancing 132, 135, 190, 542 Stamps, Timothy 666
socialism 33, 239, 445, 448–49 Stanton-Jean, Michele 693
social media states 281–92. See also foreign policy
disadvantages of 379 as actors in global health politics 4
governmental control of 523 capacity to govern 147–49, 148f, 155–57
outbreak reporting through 514, 517, 519, 521 declining relevance of 281, 289–91
social medicine 22, 23, 43, 44 future research needs 292
social rights. See International Covenant on global health concerns of 286–89
Economic, Social, and Cultural Rights healthcare provisions from 23, 24, 282–85
social spaces 66 internal complexity of 281–82
social violence 379, 459 as political units of international
socio-economic status 59, 65, 152. relations 40
See also poverty role in BRICS countries 313–15
sociology, conceptualizations of power transnational 290–91
in 65–67, 73 STDs. See sexually transmitted diseases
socio-medical perspectives 26, 29, 32, 34 Stiglitz, Joseph 473, 504
soft power 72, 104, 110–11, 114, 306, 635 stigma. See also discrimination
sole proprietorships, defined 388b definitions of 66
Sommer, Marnie 332 epidemics and 20, 21, 32
Soper, Fred L. 23 of HIV/AIDS 32, 66, 94, 167, 556
Sotomayer, Arturo 202 place-based 66
South Africa. See also BRICS countries Storeng, Katerini T. 329, 374
access to medications in 613 Strange, Susan 289, 291
apartheid regime in 553 Streeck, Wolfgang 229
728   index

structural adjustment programs (SAPs) Technical Barriers to Trade (TBT)

conditionalities of 46, 353, 448, 472–73 Agreement 428, 430
criticisms of 221 technical capacity of states 147
negative impact of 454–55, 472–74 ten Have, Henk 693, 694
neo-liberalism and 38, 46–47, 371, 471–73 terrorism 6, 129, 130, 162–63, 379. See
structural power 61, 65, 71–74 also bioterrorism
structural violence 47, 52, 62–64, 72, 377, 480 Thatcher, Margaret 47, 220, 230n1, 448, 555
structural vulnerability 62–64, 72 Therborn, Göran 220
Stuckler, David 186 ‘t Hoen, Ellen F. M. 572, 605
sub-Saharan Africa Thomas, Stephen B. 68
antiretroviral access in 413, 416 Thompson, Donald 208
child mortality rates in 59 Thompson, Tommy 614
economic decline in 221 TNCs. See transnational corporations
HIV/AIDS in 128, 129, 286 Tobacco Free Initiative (TFI) 394, 631,
life expectancy in 221, 454, 458 666–71
neo-liberal shock therapies in 472 tobacco use 661–77. See also Framework
pharmaceutical sector in 311 Convention on Tobacco Control;
public health services in 88 transnational tobacco companies
structural adjustment programs in collective action for regulation of 390–91
472, 473 as commercially driven pandemic 663–64
tobacco use in 399 cost of interventions for reduction of 632
subsistence rights 499 domestic control of 307
substance use. See alcohol use; tobacco use electronic nicotine delivery systems
Sumner, Andy 285 394–95, 642
Supari, Siti Fadilah 188, 536 evidence base against 667–68
Sustainable Development Goals (SDGs) gender differences in 241–42
access to medications and 607 in global health policy agenda 328
agenda setting for 6, 329, 333 governance on 276
costs associated with 288 health effects of 661–62
foundational concepts of 578–79 mortality rates from 242, 661
gender components of 248 as NCD risk factor 629–31
on human right to health 494 reframing as public health issue 89,
for NCDs 639 665–72
neglected tropical diseases in 579 trade policies impacting 429–33, 439
as planned development strategy 218 underestimation of health risks 399
targets of 227–29, 228t, 285, 288 Tobin, John 498–99, 502
swine flu. See H1N1 Toebes, Brigit 644
symbolic power 72 TPP. See Trans-Pacific-Partnership
Szreter, Simon 126, 283 trade liberalization
economic growth through 446
T food industry and 476, 629–30
tailgate medicine 208–10 globalization effects on 6, 470
Tarrow, Sidney G. 368 health effects of 470, 629–30
Task Force for Child Survival 592, 595 non-tariff trade barriers and 436
Taylor, Allyn 666, 670 power exerted through 64
Taylor, Carl 25 transnational corporations and 427
TB. See tuberculosis Washington Consensus on 46
 index   729

Trans-Atlantic Trade and Investment as academic discipline 22

Partnership (TTIP) 107, 289, 435–41 colonialism and 20, 44, 125–26, 171, 199
transgender populations 66, 240, 252 exclusionary nature of 189
transitive power 72 gender in 248
transmissible chronic diseases 647 Rockefeller Foundation division of 23
transnational corporations (TNCs) True, Jacqui 248
cash reserves held by 292n3 Trump, Donald
consolidation of ownership 388, 393 America First policies of 287
food and beverage 477 antiglobalism of 39, 53
good governance lexicon in 455 election of 10
intellectual property protections for 107 ideological undermining of truth by 115
investor-state dispute settlement for on US withdrawal from TPP 440, 441
436–37, 477 TTCs. See transnational tobacco companies
power of 369, 388 TTIP (Trans-Atlantic Trade and Investment
public policy influence of 64 Partnership) 107, 289, 435–41
regulatory cooperation mechanisms tuberculosis (TB). See also Global Fund to
and 438–39 Fight AIDS, Tuberculosis and Malaria
reputation management by 395 agenda setting on 327, 328, 331
role in global economy 291 in BRICS countries 309
standard setting influenced by 398–99 global surveillance systems 518–19
tax avoidance by 288, 370 outbreak reporting 517
trade liberalization and 427 as re-emerging disease 88
value chains controlled by 476 vaccination for 585–88, 599
vulnerability of workers in 169 Turner, Ted 410, 670
transnational tobacco companies (TTCs) typhus 585–86
consolidation of 391
expansion into emerging markets 663 U
harm-reduction initiatives 676–77 UDBHR. See Universal Declaration on
on illicit tobacco trade 675–76 Bioethics and Human Rights
marketing tactics used by 391 UDHR. See Universal Declaration of Human
political repositioning of 394 Rights
profitability of 662 UHC. See universal health coverage
Project Cerberus developed by 672 UN. See United Nations
standard setting influenced by 398–99 UNAIDS. See Joint United Nations
venue shopping by 439 Programme on HIV/AIDS
Trans-Pacific-Partnership (TPP) 107, 116n3, UNDP (United Nations Development
289, 399, 435–41 Programme) 144–46, 454, 591
travel restrictions UNESCO (United Nations Educational,
for Ebola virus 136–37, 190–91, 331 Scientific, and Cultural
health security and 136–37, 165, 189–91, 207 Organization) 685, 688–90, 693–95
HIV/AIDS and 331, 556 UNFPA (United Nations Population
H1N1 and 136, 331 Fund) 28, 356, 397
SARS and 269, 331, 351 UNGA. See United Nations General
TRIPS. See Agreement on Trade-Related Assembly
Aspects of Intellectual Property Rights UNIATF (United Nations Interagency Task
tropical medicine. See also neglected tropical Force on NCDs) 639, 640, 642
diseases UNICEF. See United Nations Children’s Fund
730   index

Unilever 395 United Nations Children’s Fund (UNICEF)

unintentional (immanent) development 217, Child Survival Revolution 49, 326, 450
218–23, 229 establishment of 23, 586–87
UNITAID 397, 607, 615, 616 on influenza pandemic
United Kingdom preparedness 538–39
alcohol use patterns in 242–43 on primary healthcare 30, 31, 49, 449, 506
Brexit vote in 10, 441, 563 on structural adjustment programs 454–55
Department for International vaccination support from 586–87, 591,
Development 205, 303, 325, 674 596, 597
development assistance from 287 United Nations Development Programme
global health diplomacy by 109, 112–13 (UNDP) 144–46, 454, 591
HIV/AIDS public information campaigns United Nations Economic and Social Council
in 555 (ECOSOC) 238, 247, 639
influenza vaccination campaigns in 533–34 United Nations Educational, Scientific, and
life expectancy in 219 Cultural Organization (UNESCO) 685,
medication stockpiles held by 137 688–90, 693–95
military assistance from 204–6 United Nations General Assembly (UNGA)
National Health Service 447–48, 586 xiii, 325, 634, 637–39, 642–43
privatization in 47, 230n1 United Nations Interagency Task Force on
Social Issues Research Centre 376 NCDs (UNIATF) 639, 640, 642
tobacco use patterns in 242 United Nations Population Fund
tropical medicine schools in 22 (UNFPA) 28, 356, 397
utilization of health services in 245 United Nations Security Council (UNSC)
vaccination adoption in 584–86, 598 on Ebola outbreak 191, 271, 331
United Nations (UN) functions of 325
on antimicrobial resistance 131 HIV/AIDS on agenda of 128–29, 133–34, 331
Commission on HIV/AIDS and Resolution 1308 adopted by xiii, 110, 271,
Governance in Africa 560 557–58
Commission on Human Security 147, Resolution 2177 adopted by 191
149–56, 158n1 United States
Convention on the Rights of the biodefense activities conducted by 181–83
Child 494, 644 bubonic plague in 21
establishment of 23 cigarette flavouring dispute with
Global Compact 370 Indonesia 429–33
on HIV/AIDS as security issue 94 in Cold War 24–25, 87
on influenza pandemic preparedness 535 Declaration of Independence 495–96
International Covenant on Civil and development assistance from 109,
Political Rights 494–95, 497–501 286–87, 310
International Covenant on Economic, disease eradication efforts in 596
Social, and Cultural Rights 106, 144, Ebola outbreak response by 123–24
494, 497–502, 637 global health funding from 25–26, 31, 53
MDGs. See Millennium Development health inequality in 59
Goals health security threats to 94, 123–24
negotiation of health issues by 105 influenza vaccination campaigns in 533–34
Responsibility to Protect agenda 5, 272, 499 isolationist policies of 22
SDGs. See Sustainable Development Goals Marshall Plan implemented by 224
Universal Declaration of Human MEDCAP use by 208–10
Rights 144, 496, 497, 499 medication expenditures in 619
 index   731

medication stockpiles held by 137 scope of program 134

military assistance from 200, 204–6 “utopia as method” approach 75
neo-liberal economic policy in 45
privatization of healthcare in 47 V
September 11 attacks (2001) 6, 129, 130, vaccinations 583–600. See also Global
162–63, 379 Alliance for Vaccines and
Universal Declaration of Human Rights Immunizations
(UDHR) 144, 496, 497, 499, 691 access to 42, 188, 397, 536, 544–45, 607
Universal Declaration on Bioethics and BCG 585–88
Human Rights (UDBHR) 685–97 Children’s Vaccine Initiative 593–94
criticisms of 685–86, 693 Cold War rivalries and 588
on cultural diversity 690–94 compulsory 165, 584, 598
legitimacy of 686, 689, 690, 694 diphtheria 584–85
objectives of 689 economic globalization and 592–96
on pluralism 691–93 global politics of 597–600
as political document 692–93 GOBI interventions and 30, 31, 49, 450
preamble to 690–91 hepatitis B 206, 598, 599
refinement of 696–97 influenza 186, 188–89, 531–41, 544–45
terminology considerations 686–88, 695 mass vaccination campaigns 586–88
universality of application 686, measles 598
689–90, 696 opposition to 585, 587
universal health coverage (UHC) overview 583
advocacy for 473 poliovirus 206–8, 583, 588
in BRICS countries 309, 315–16 production centers for 311–12, 597
erosion of support for 454 profitability of 600
funding for 285, 288, 291 as public health tool 584–86
on global health agenda 283, 286, 329 R&D investment in 532, 539, 593, 597
mechanisms for achievement of 460–61 rotavirus 599
monitoring framework for tracking smallpox 198, 552, 583, 584, 589–90, 599
progress toward 304 standardization of 598
NCDs and 645 tuberculosis 585–88, 599
opposition to 507 typhus 585–86
political nature of 283–84 WHO programs for 206, 590–92
WHO support for 506 yellow fever 415, 416
universalism, in bioethical frameworks vaping 394–95
686–90, 692, 694–96 Vaughan, Patrick 664
UNSC. See United Nations Security Council violence
US Agency for International Development in civil-military relations 202
(USAID) 26–28, 30, 49, 205, 397 collective 151
US Declaration of Independence genocide 153, 499
(1776) 495–96 global health and 150–54
US President’s Emergency Plan for AIDS human security and 150–54
Relief (PEPFAR) interpersonal 151, 152, 157
funding for 225, 274, 287, 333 self-inflicted 151
generic medication purchases by 616 sexual 151, 153
as global health diplomacy 108, 110, 114 social 379, 459
motivations for formation of 270, 272, structural 47, 52, 62–64, 72, 377, 480
560, 615 women and 152–53, 248, 335
732   index

von Hayek, Friedrich 220, 230 Wilsnack, Richard W. 242

von Unger, Hella 70 Wilsnack, Sharon C. 242
vulnerability WIPO (World Intellectual Property
actual vs. potential 169 Organization) 360
in conflict areas 152, 153, 157 WMA (World Medical Association) 688
in critical security studies 168–70, 173 Wolff, Jonathan 169
defined 168 women. See also gender
to disease 33, 39, 126, 128, 173 in conflict areas 153, 157
income inequality and 47 discrimination against 70
intersectionality and 241 family-planning programs targeting 28
relational view of 169–70 menstrual hygiene management for
stigma as reinforcement of 66 331, 332
structural 62–64, 72 in poverty 153–54
reproductive health of 53, 153, 243–44,
W 248, 333
Wallgren, Arvid 585 violence against 152–53, 248, 335
Walsh, Julia A. 249, 506 Woodling, Marie 329
Walt, Gill 90, 112, 327 Woods, Ngaire 474
Waltz, Kenneth 8 World Bank
Wang, Yingying 245 as actor in global health politics 4, 218,
Warren, Kenneth S. 249, 506 271, 349
Washington, George 198 agenda setting by 225, 326
Washington Consensus conditions for loans from 593
healthcare reform influenced by 454, 456 Curbing the Epidemic report 631, 668
inadequacies of 48, 456 epistemology of hunger 353–54
on market-based efficiency 446 good governance lexicon in 455
neo-liberalism of 38–39, 45–47, 220, 225 on influenza pandemic preparedness 535,
New Washington Consensus 49–52 538–39, 542
origins of term 45–46, 288 Investing in Health report 33, 50–51, 450,
Wasunna, Angela A. 571 473, 551, 612
Watson, James L. 128 Pandemic Emergency Financing
Watson, Scott 189 Facility 359, 542
Weir, Lorna 166 policymaking influences 50, 51, 92
Weisbrod, Burton 414 poverty as defined by 285
welfare state 64–66, 447, 448 on primary healthcare 49
Wellcome Trust 4, 411 response to debt crises 38, 45–46, 88, 471
Wendt, Alexander 493 structural adjustment programs 38, 46,
West Africa Ebola outbreak. See Ebola 221, 353, 371, 448, 471–73
virus disease in transnational state 290
What Is Enlightenment (Kant) 86 on universal health coverage 473
Whiteside, Alan 551 World Economic Forum 6, 53, 229, 594,
WHO. See World Health Organization 597, 670
Wilkinson, Richard 552, 565n2 World Health Organization (WHO)
Williams, Michael C. 162 as actor in global health politics 4, 349
Williams, Owain David 271, 329 agenda setting by 326, 330
Williamson, John 45–46, 50 on antimicrobial resistance 131
 index   733

BRICS countries’ involvement with 304, outbreak reporting to 513–19, 522–24

307, 314 Pandemic Influenza Preparedness
bureaucratization and 350 Framework 185, 188–89, 306,
CIOMS established by 688 536–37, 544
Commission on Macroeconomics and policymaking shifts at 50, 51, 93
Health 51, 472, 573 on population control 28
Commission on the Social Determinants of preamble to constitution of 24, 27, 44
Health 48, 59, 238, 470, 552 on primary healthcare 31, 49, 449
criticisms of 9, 33, 265 Revised Drug Strategy 609, 610
on diet and physical activity 115, 636, 641 SARS outbreak response 269, 351
diplomatic instruments of 112b, 353 Set of Recommendations on the Marketing
Ebola outbreak response 9, 265, 275, 359 of Food and Non-alcoholic Beverages to
Essential Medicines List 608–10, 615 Children 115, 633
establishment of 19, 24, 218, 247, 266 Tropical Diseases Research program 248
FCTC. See Framework Convention on on universal health coverage 506
Tobacco Control vaccination programs 206, 590–92,
fragmentation within 352, 355 595–97
Framework for Engagement with vertical campaigns of 26–27
Non-State Actors 375 violence as categorized by 151
functions of 325, 348–49 weakening of 373–74
funding for 25–26, 274, 373, 409 World Intellectual Property Organization
Global Code of Practice on the (WIPO) 360
International Recruitment of Health World Medical Association (WMA) 688
Personnel 112b World Trade Organization (WTO). See also
Global Health Workforce Network 246 Agreement on Trade-Related Aspects of
Global Influenza Surveillance Intellectual Property Rights
Network 188, 533, 534, 536 on compulsory licensing for generics 613,
Global Programme on AIDS 352, 614, 617
358–59, 556 dispute settlement mechanisms
Global Strategy to Reduce the Harmful use 429–35, 455
of Alcohol 112b, 391 establishment of 428, 441, 474
Health for All by the Year 2000 strat- General Agreement on Trade in
egy 30, 371, 495, 505, 608 Services 428, 434, 452
on health security 128, 186 negotiation of health issues by 105
HIV/AIDS epidemiological scenarios policymaking influences 92
developed by 556–57 SPS Agreement 428, 434
IHRs. See International Health Technical Barriers to Trade
Regulations Agreement 428, 430
international development efforts in transnational state 290
of 224–25 US-Indonesia dispute on cigarette
legitimacy challenges for 111–12, 671–72 flavouring 429–33
on NCDs 393, 633, 635–43 Worsnop, Catherine 353
on neglected tropical diseases 569, 571–72 WTO. See World Trade Organization
negotiation of health issues by 105
normative power for health X
promotion 111–12, 273 Xi Jinping 305
734   index

Y Youde, Jeremy 1, 52, 93, 271, 409

Yach, Derek 394, 666–67, 670, youth. See children and adolescents
673
yellow fever Z
International Health Regulations Zaki, Ali Mohamed 520–22, 525n5
on 25 Zhadnov, Victor 589
quarantine regulations for 126 Zika virus 103, 166, 201–3
as re-emerging disease 32 Zimmer, Zachary 153
transmission of 20–21 zoonotic diseases 127, 532, 551, 554, 572
vaccination for 415, 416 Zuckerberg, Mark 4, 413